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Working with Audit Guidelines

Rahul Mishra
Updated

Audit guidelines include the instructions and settings that govern each audit project. They serve as a central resource for defining audit scope, outlining requirements, and specifying which sections appear in reports.

Each account must have at least one Global Audit Guideline set up under Admin > Manage Audit Settings. Most organizations create multiple guideline templates to match the unique scope and reporting needs of different audit types. For example, an E/M Office guideline might require documentation for HPI and medical decision-making, whereas a surgical audit may not. For HCC risk audits, it's important to select the correct risk adjustment models and enable HCC descriptions as needed.

Users can easily clone, edit, or inactivate audit guidelines. Inactivating a guideline ensures it won’t be used in new projects, though it will still be available for ongoing ones. Only Active guidelines appear when creating new projects or assigning audits.

Choose the desired version of Audit Manager+ to see the relevant steps:

Audit Manager+ Enterprise

Follow these steps to start working with Audit Guideline using the Enterprise version:

  • Navigate to the Admin Manage Audit Settings. The Audit Guidelines window will be displayed
  • This screen displayed the guideline name, claim type, last modified date, and status of the individual guideline.

  • Under the Actions menu, you can perform the following functions:

    • Show/Hide – Toggle the visibility of guidelines in the list.  
    • Add Guideline – Create a new audit guideline template. The user can refer to the Add Guideline and follow the instructions.
    • Edit Guideline – Modify the details of an existing guideline. The user can refer to the Edit Guideline and follow the instructions.
    • Copy Guideline - Allows users to clone the existing guideline. The user can refer to the Copy Guideline and follow the instructions.
    • Activate Guideline – Make a previously inactive guideline available for use in new projects. The user can refer to the Activate Guideline and follow the instructions.
    • Inactivate Guideline – Disable a guideline to prevent it from being used in future projects (it will remain available for ongoing audits). The user can refer to the Inactivate Guideline and follow the instructions.
    • Add Logo – Upload a logo to include in the audit report headers. The user can refer to the Add Logo and follow the instructions.
  • The Toggle button allows users to switch between viewing active and inactive guidelines on the Audit Guidelines List page.

Audit Manager+ Multi-Account 

Follow these steps to start working with Audit Guideline using the Multi-account version:

  • Navigate to the Admin Manage Settings.
  • This screen displayed the guideline name, type of claim, last modified date, and status of the individual guideline.

  • Under the Actions menu, you can perform the following functions:

    • Show/Hide – Toggle the visibility of guidelines in the list.  
    • Add Guideline – Create a new audit guideline template. The user can refer to the Add Guideline and follow the instructions.
    • Edit Guideline – Modify the details of an existing guideline. The user can refer to the Edit Guideline and follow the instructions.
    • Copy Guideline - Allows users to clone the existing guideline. The user can refer to the Copy Guideline and follow the instructions.
    • Activate Guideline – Make a previously inactive guideline available for use in new projects. The user can refer to the Activate Guideline and follow the instructions.
    • Inactivate Guideline – Disable a guideline to prevent it from being used in future projects (it will remain available for ongoing audits). The user can refer to the Inactivate Guideline and follow the instructions.
  • The Toggle button allows users to switch between viewing active and inactive guidelines on the Audit Guidelines List page.

Add Guideline

Follow these steps to add a new audit guideline:

  • Navigate to the Actions menu and select Add Guideline. This will open the Add Guideline window.
  • Under the General Information tab, type the appropriate Guideline Name in the desired field.
  • Choose one of the following types of claims, as needed:
    • Professional: Used to creating audit guidelines for claims related to the audit manager professional. 
    • Facility:  Used for creating audit guidelines for claims related to the audit manager +.
    • Dental: Used for auditing claims that pertain specifically to dental services and procedures.

Note: AM+ users will only have access to the claim types they have purchased and activated in Client Settings. If a required claim type is not listed, please contact the support team for assistance.

  • The Default Audit Guideline for Type of Claim checkbox designates the selected guideline as the default template for that specific type of claim (e.g., Professional, Facility, or Dental).  

  • Under the Scope of Audit, the user can select the desired checkbox for the Audit Type. This defines the focus and boundaries of the audit, specifying which areas, services, or claims will be reviewed.

  • If there is any additional information related to the Type of Claim, the user can enter it in the Notes section.
  • Enter the desired date for the records to be reviewed. 
  • Select the appropriate Method of Record Transfer from the dropdown list. If Others is selected, please provide the necessary details in the Method of Record Transfer Other field.
  • Select the desired QA Review Instructions from the options available (100%, Detailed, Brief, or Others). If Others is chosen, please enter the required details in the QA Review Instructions - Other field.
  • Select the desired Frequency from the drop-down options. If Other is chosen, please enter the required frequency details in the Frequency Other field.
  • Select the desired Turn Around Time (TAT) from the drop-down list to specify the amount of time allotted for completing a task or process, from initiation to completion. If Others is chosen, please enter the required time details in the Turn Around Time Other field.
  • Choose the desired DOS Identification radio button:
    • Patient ID Field: To identify the Date of Service (DOS) based on a particular Patient ID.
    • Patient Name Field: To identify the Date of Service (DOS) based on a particular Patient name.
  • Write the DOS Identification Notes in the designated field, if applicable.
  • Write the Process Instructions in the designated field, if applicable.
  • Enter the desired Pass Rate Threshold to set the % of accuracy a provider should meet in order to pass this audit. This threshold is also utilized in the E/M Audit Failure report. Enter only a numeric value. If there is any additional information, mention it in the Pass Rate Threshold comment box.
  • Enter the number of Providers.
  • Select the number of DOS for Providers using the drop-down list. If Other is selected, type the desired number of DOS in the appropriate field.
  • Add Custom Criteria as needed to specify any additional requirements or conditions.
  • Under the Application Medical Specialties, use the desired arrow sign and select the appropriate medical specialties. 

  • Refer to the Defining New Audit Guideline Elements (The article is currently under review and will be published soon) to add Audit Guideline Elements-related details.
  • Refer to the Mid Level Guideline Elements (The article is currently under review and will be published soon) to add Mid Level Guideline Elements-related details.
  • Refer to the Lab and Diagnostic Guideline Elements (The article is currently under review and will be published soon) to add Lab and Diagnostic Guideline Elements details in the Audit Worksheet.
  • Refer to the Surgical Guideline Element (The article is currently under review and will be published soon) to add Surgical Guideline element-related details in the Audit Worksheet.
  • Refer to the Report Parameters Elements (The article is currently under review and will be published soon) to add report elements in the Audit Worksheet reports.
  • Once all the elements are defined, click on the Save.
  • Click the Data Elements tab to select the specific data elements to include in the audit guideline and display during the audit review process. The user can also refer to the Data Elements article and follow the instructions. 
  • You can also click on the AM+ Report Settings tab to select which summary tabs should appear in the Report Preview Box on the Audit Overview page. Refer to the AM+ Report Settings (upcoming) article and follow the instructions.

Edit Guideline

Follow these steps to edit an existing guideline:

  • Select the checkbox located before the guideline name you want to edit.
  • Navigate to the Actions menu and select Edit Guideline. This will open the Audit Guideline window.
  • Update the desired information using the General Information, Data Elements, and AM+ Report Settings tab and click Save to finalize the changes.

Copy Guideline

The Copy Guideline simplifies the process of creating a new Audit Guideline based on an existing one. When you choose this option, all attributes, configurations, and rules from the original guideline are copied into a new, editable version. This saves time by avoiding manual duplication and helps maintain consistency when developing similar guidelines.

Follow these steps to copy an existing Audit Guideline:

  • Select the checkbox in front of the guideline name you wish to copy.
  • Go to the Actions menu and choose Copy Guideline. This will open the Audit Guideline window.
  • You can rename the guideline and update the desired information using the General Information Data Elements, and AM+ Report Settings tab.
  • Click Save to finalize the changes.

Note:

  • A cloned guideline is created in Draft status and can be edited before activation.
  • A cloned guideline does not carry over any project associations.

Activate Guideline 

Follow the steps below to activate the desired inactive guideline:

  • Select the checkbox located before the guideline name you want to activate.
  • Navigate to the Actions menu and select Activate Guideline.
  • A confirmation message will appear once the guideline is successfully activated.

Inactivate Guideline 

Follow the steps below to inactivate the active guideline:

  • Select the checkbox located before the guideline name you want to inactivate.
  • Navigate to the Actions menu and select Inactivate Guideline.
  • A confirmation message will appear before proceeding with guideline inactivation.
  • Click OK. The guideline will be inactivated, and a confirmation message will be displayed.

Add Logo 

Follow the steps below to add a logo:

  • Navigate to the Actions menu and select Add Logo.
  • Browse and select the desired logo file.
  • The added logo will be displayed next to the search bar, along with a Delete Logo option.

Note: Once a logo is added, the Add Logo option will no longer appear in the Actions menu.

 

© Healthicity, LLC

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