Documentation Audits

Above and beyond apparent patient care concerns, poor documentation can have a serious impact on health care organizations. The lack of complete documentation in patient medical records can result in errors in reimbursement, statistics, financial planning and clinical data. The goal of documentation is to provide sufficient and accurate clinical data for correct coding and billing for all services provided to the patient. Missing or incomplete documentation can lead to unbilled or denied charges, which leads to significant lost revenue.

Many on the "risk areas" identified by the OIG depend on the level of documentation. BKD Health Care Group can assist in obtaining clear, complete, pertinent and accurate documentation. BKD provides documentation reviews that focus on:

Potential Benefits to You
  • Improves compliance
  • Identifies revenue opportunities
  • Improves patient care
  • Improves clinical data for research and education
  • Protects the legal interest of the patient, facility and physician
  • Achieves accurate case mix index by correctly coding from proper documentation
  • Analysis of documentation for content and validity/medical necessity relationship
  • Analysis of documentation in relationship to coding and billing
  • Identification of patterns and trends in documentation
  • Identification of risk areas in documentation, i.e. illegibility or improper use of symbols and abbreviations
  • Analysis of documentation for compliance issues
  • Education and training on documentation improvement opportunities
Request a call from a BKD advisor

For More Information

Contact your BKD advisor or:

R. Scott Vaughn
800.581.4290