Audit Guidelines General Information

This article will over Audit Guidelines within Audit Manager. please click a section below in blue, to jump to that section.

• What are Audit Guidelines?
• Audit Guidelines Settings Overview
  • General Information
  • Audit Parameters / Guidelines
  • Mid Level Guidelines, Lab and Diagnostics Guidelines, Surgical Guidelines 
  • Assign Report Parameters
• Creating a Guideline
• Edit Global Audit Guidelines
• Edit Audit Guidelines for an Individual Project

For a more in-depth look at guidelines, please watch our webinar on Audit Guidelines within Audit Manager (Legacy)

• Tuesday Tips and Tidbits: Master Audit Guidelines for Project Success

 

What are Audit Guidelines?

Audit Guidelines are instructions and settings that govern each audit project. They provide an accessible location to share instructions, audit scope, set audit requirements, and control which sections display on reports.

Each account must have at least one Global Audit Guideline in their system.

 

 

Audit Guidelines Settings Overview

The audit guidelines are project settings that govern which fields are required in the audit box, which auditing features are enabled and what is displayed in reports. Most of the fields within the Audit Guidelines are informational only; they do not have a downstream impact on the audit or reports.

Generally, the informational fields are used by Consulting Clients to capture the scope of work, specific requirements, and communicate to auditors how their client wants different scenarios handled within the audit. Auditors can view the audit guideline information directly from the audit box by clicking on the question mark in the upper left of the audit box.

 

 

General Information

Note: Fields in gray are INFORMATIONAL ONLY; green fields have a downstream effect on the audit or the reports.

See the corresponding descriptions for the red numbered fields below:

1. HCC scope checkbox turns on the HCC auditing features within the audit box.
2. Risk Adjustment Model drop down allows users to select their desired risk model and version.
   
   
3. DOS Identification determines whether patient name, Patient ID, or both display on reports.
4. Passrate Threshold settings are ONLY for the custom report E/M Audit Failure report. Users determine passing and failing accuracies that display as P or F in the report.
   

 

Audit Parameters / Guidelines

Note: Fields in gray are INFORMATIONAL; fields in green have a downstream effect on the audit or the reports; fields in yellow are legacy settings for 95/97 features.

See the corresponding descriptions for the red numbered fields below:

5. Place of Service Required makes this field within Patient Data section required.

6. Chief Complaint Required makes this field within Patient Data section required.

7. Chief Complaint Description Required forces the auditor to record the chief complaint into the Patient Data section of the Audit Box.

8. ICD-10 Assessment Required is a legacy feature when the industry converted from ICD-9 to ICD-10. This turns on additional fields in the scoring ICD/EM/CPT/HCPCS Codes Section that allow auditors to crosswalk 9 to 10 and mark whether 10 is supported. (see below)

9. Payer Type Required makes this field within Patient Data section required.

10. Run Edits Required makes this button in the ICD/EM/CPT/HCPCS Codes Section required, it displays a yellow triangle, when clicked, describes the potential NCCI edits (ex. Bundling issues, ages & gender code issues, etc.). (see below)

 

Audit Parameters / Guidelines continued

11. E/M 2021 Assessment Required is a legacy feature utilized during the transition from 95/97 guidelines to AMA Guidelines. This feature allows auditors to enter an ‘audited code’ based on 95/97 and a ‘2021/2023 audited code’ based on AMA. The report developed with this feature has both ‘audited codes’ on the report. (see below)

12. Prolonged Services Default allows users to default to either AMA or CMS prolonged service codes when using Time-based Coding.

13. Documentation Elements Required forces auditors to open the Documentation Elements section of the Audit Box and check one box (no issues if nothing applies). Auditors will not be able to ‘Complete’ the audit until something is checked. (see below)

 

 

Mid Level Guidelines, Lab and Diagnostics Guidelines, Surgical Guidelines

All of these fields are INFORMATIONAL only.

 

 

Assign Report Parameters

The following settings (1 – 12) control features on Reports. This includes elements in the Provider/Coder Detail Report header, and which code accuracy tables display on the Provider Detail, Project Detail and Project Summary Reports.

 

The following settings (13-15) determine whether to display the Competency Findings, Key Findings & Recommendations, and whether your Key Findings appear directly beneath the Competency Section or start at the beginning of the next page.

 

The following settings (16-19) determine which columns display in the Audit Details for each encounter and the signature at the end of the report.

 

Assign Report Parameters Continued

20. Gives users the ability to include uploaded patient records for all encounters or for only encounters that contain errors.
Note: In order to include patient records with reports, they must first be loaded into the Records page of the application.

21. Project Detail Report Specific: Allows users to choose whether to include the Audit Details summary for all encounters in the entire project, or only encounters that contain errors.

Note: This feature is helpful due the volume of encounters summarized in a Project

 

 

Creating a Guideline

To create a new Audit Guideline, navigate to:

Enterprise Clients can navigate to: Admin>Manage Audit Settings>Audit Guidelines>Add Guideline

Consulting Clients can navigate to: Admin>Manage Settings>Audit Guidelines>Add Guideline

 

 

Edit Global Audit Guidelines

To make changes to the global guidelines click the pencil icon to the right of the guideline you want to update. (see images above based on your account type)

 

 

Edit Audit Guidelines for an Individual Project

Once a guideline is applied to a project, it can be modified to the needs of the audit. To make edits to the a Guideline that governs a specific project, navigate the following:

Enterprise Clients: Audit > Manage Project > Click the edit button to the far right of the project to edit.

Consulting Clients: Client>Click on a client name in blue>Audit Projects>Click the pencil icon to right of project to edit.

 

 

Creating a Project from an Audit Guideline

Now that you've created your Audit Guideline, you will need to create a project to house your audits. Upon project creation, users select one of the preset global (or client) Audit Guideline templates, allowing users to quickly apply the requirements and report settings to all the audits within that project.

To create a project, follow the navigation guide below, based on your account type below.

Enterprise Clients: Admin>Manage Projects> Create a New Project > on the far right there is a drop-down Guideline selection.

Consulting Clients: Client>Click on a client name in blue>Audit Projects>Create New Project