Medical Chart Review

Under-Coding Impact

The following is an example from a clinic of 18 primary care providers with an average clinician FTE of 0.8

  • Annualized utilization of 99214 = 6,789
  • Utilization after chart review and training 99214 = 9,780
  • Difference = 2,991 X $34 = $101,694

AAPC Physician Services has performed tens of thousands of chart reviews around the country for health care providers who are not only getting educated on documentation and coding compliance but are also using the information to strengthen their revenue streams in an era of reform.

Every Chart Review Includes:

  • A quality review of each chart's documentation and coding by a certified professional medical auditor.
  • A detailed audit report of the findings along with recommendations and cross references to coding guidelines.
  • A consultative session to review the audit report and provide training and education based on the findings.

Our chart review process follows a structured methodology designed to identify improvement opportunities through a comprehensive assessment of documentation, coding, and billing. This approach identifies gaps between existing processes and national best practices:

Auditor assigned Step 1 – Auditor assigned
An auditor will be assigned to your project by matching the expertise of the auditor with your specialty. All auditors used by AAPC Physician Services are Certified Professional Medical Auditors (CPMAs) who have passed rigorous testing and qualification requirements.
Chart review performed Step 2 – Chart review performed
Chart reviews are typically performed remotely. We will work with you to identify the most appropriate method to obtain access to those records selected for the review.
Review by senior auditor Step 3 – Review by a senior auditor
A senior auditor reviews and validates each chart audit, including the audit findings and recommendations. This multi-layer review provides further validation that your audit findings are complete and accurate.
Report of findings Step 4 – Report of Findings
Each chart review includes a detailed written report listing errors identified during the audit, potential utilization issues, and potential financial impact. Reports will also include documentation tips and improvement recommendations based upon the audit findings.
Training Step 5 – Training
A consultative meeting to review the results of the audit report, discuss key findings and provide education and training on identified areas needing improvement.

Guarantee: We believe in earning your trust. If you are not satisfied we made you better, we will return your money.