We provide Medical Chart Audits and Medical Records reviews for Evaluation and Management (E/M) services and/or Procedural/Surgical services.

Option 1

We offer E/M chart audits and records reviews. We audit based on the AMA CPT® 2021 and 2023 Evaluation and Management current Documentation Guidelines for Office and Other Outpatient visits, Hospital Visits, SNF and Nursing Visits, Home Visits, Prolonged Services, and other E/M encounters.

*If we are auditing before CY 2021 dates of service, we will use the 1995/1997 Documentation Guidelines that were valid for that period. E/M CPT® codes (e.g., Initial Hospital Visits, Subsequent Hospital Visits, Observation, Office and Other Outpatient encounters, etc.)

We are in keeping with current Medicare and CPT® AMA Documentation Guidelines, along with the CMS payer published rules and guidance. No practice is too small or too large. We can tackle whatever size practice you have. We limit our scope to “professional Physician and Qualified Healthcare Provider services” and do not provide audits for facilities ( e.g., hospital DRGs or ASC).

To inquire about a proposal and quote, please fill out our quick web form for more details. You can also email Terry Fletcher directly at TerryFletcherCPC@aol.com or call us at 714-746-3077.

Option 2

We offer remote Procedural Chart/Records reviews based on your specialty. (example, Cardiology – Heart Cath’s, PCI, Device Implants, Office Diagnostics, Peripheral Procedures, etc). We review for compliance as well as determining if you are capturing all your procedural services based on your procedure/operative reports. Many practices under-code their procedures or miss capturing components of many procedures. Check today to make sure you are maximizing your coding and reimbursement.

We are here to make sure you are capturing all legally billable services, but are also in compliance and not over-coding your services that could trigger a payer audit.

Call  714-746-3077 or fill out our quick web form for a quote or more details. Fees are per record to start.

*Coding Corner Membership clients receive discounted rates on Medical Record Audits.