Plan - answer✔Treatment
You are performing an audit of e/m services for a FP office. In the encounter you read the
physician ordered and reviewed a differential WBC. What elements would you expect to see in
the medical records? - answer✔Patient ID, assignment of benefits, pt's medical hx,
immunizations, physical examination, lab report, clinical impression & physician orders. When
labs are ordered, there must be a copy of the order and the lab report that the physician has
reviewed.
What is the minimum requirement for the signature of the author of an entry in the medical
records? - answer✔The first initial, last name and credentials
Based on JCAHO accreditation guidance for personal data, what two elements must be evident
in the medical records? - answer✔Personal biographical data and consent for Treatment or
authorization for Treatment form.
What is a comprehensive/focus review audit? - answer✔A large number of claims are selected
for review that might be focused on specific procedure and/or dx codes
What is RAT-STATS used for by an auditor? - answer✔Software used in performing statistical
random samples and evaluating results.
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