Coding & Clinical Documentation Audit

By conducting regular audits, providers can avoid costly mistakes and reduce the risk of audits from insurance companies. This can ultimately lead to improved revenue and compliance with regulations and guidelines.

Ensure Compliance And Maximize Your Reimbursements With Us

TriumpHealth offers medical coding audit and clinical documentation audit services to detect bottlenecks, streamline the coding and billing processes. Our auditing services include reviewing coding documentation and fee schedules, analyzing payer reimbursements, identifying the trends and root causes for claim denials, and training the billing staff with process improvements and best practices.

Why Do We Conduct A Medical Coding Audit?

Coding audits provide significant value to healthcare organizations, including:

  • Compliance: Coding audits help ensure compliance with coding guidelines, regulations, and documentation requirements. By conducting regular audits, organizations can identify coding errors, potential fraud or abuse, and areas of non-compliance. This helps mitigate the risk of penalties, audits, and legal issues related to improper coding practices.
  • Revenue Integrity: Accurate and compliant coding is essential for optimal reimbursement. Coding audits help identify under coding or missed opportunities for proper coding, leading to potential revenue loss. By ensuring accurate coding, organizations can maximize their revenue potential and avoid revenue leakage.
  • Documentation Improvement: Coding audits provide insights into documentation deficiencies and gaps that impact coding accuracy. By identifying areas of improvement, organizations can focus on enhancing clinical documentation to support accurate coding, resulting in more complete and specific documentation of patient encounters.
  • Quality Improvement: Coding audits contribute to quality improvement efforts by identifying patterns or trends in coding errors. This helps organizations implement targeted education and training programs for coding staff to improve coding accuracy and consistency. Accurate coding also supports the generation of reliable healthcare data for research, analytics, and quality reporting purposes.

How Do We Help?

Our highly skilled and experienced staff are certified, and each has a minimum of 5 years of experience in the specialty that you require. We provide assistance to individuals and groups of providers within 57 specialties and 14 facility types. For each of these specialties/facility types, we will request documents such as the following to complete audits:

  • Copies of dictated or handwritten narrative operative/procedure reports
  • Medical records
  • Patient demographics
  • Copies of the claim form for each case or encounter reviewed

TriumpHealth’s expert staff will review medical records to analyze the accuracy of the procedural and diagnostic coding provided. Each review will include a case-by-case coding analysis that will compare your original coding with our experts coding. Areas of focus include incorrect code selection, unbundling issues, missed coding opportunities, code assignment that is not supported by documentation, code order, modifier usage, and documentation deficiencies.

Stay Compliant & Optimize Your Reimbursements With Us!

Our experienced staff provides a useful resource for healthcare organizations looking to achieve greater precision, compliance and revenue. Due to years of experience providing high quality medical coding audit services, TriumpHealth is considered to be one of the best medical coding auditing companies.

Frequently Asked Questions

What is the purpose of a coding and clinical documentation audit in healthcare, and how does it contribute to the overall quality of patient care and financial performance?

A coding and clinical documentation audit in healthcare ensures accuracy and compliance in coding practices, enhancing patient care quality and financial performance by reducing errors, improving documentation, and optimizing reimbursement.

What key elements or areas are typically assessed during a coding and clinical documentation audit, and how do these impact the accuracy of medical coding and patient records?

Typical audit areas include documentation completeness, code accuracy, guideline adherence, and medical necessity documentation, all crucial for accurate coding and recordkeeping.

How often should healthcare organizations conduct coding and clinical documentation audits, and what factors should be considered in determining the frequency of these assessments?

Audits should occur at least annually, with frequency tailored to organization size, complexity, and regulatory changes.

What methodologies or criteria are used to evaluate the performance of medical coders and the quality of clinical documentation during an audit, and how are audit findings communicated and addressed?

Evaluation criteria include coding accuracy rates, guideline compliance, and documentation completeness, with findings communicated via formal reports and addressed through targeted interventions.

In what ways can the results of coding and clinical documentation audits be used to improve coding accuracy, enhance compliance, and optimize reimbursement for healthcare services provided?

Audit results drive improvements in coding accuracy, compliance, and reimbursement by identifying areas for enhancement, guiding education and training initiatives, and informing strategic decisions.

Our Process


Chart Retrieval and Review

Obtain clinical charts and documentation related to patient encounters from healthcare facilities or electronic health records (EHR) systems.


Coding Audit

Evaluate the accuracy and completeness of medical codes assigned to diagnoses, procedures, and services documented in the clinical charts, ensuring alignment with coding guidelines and regulations.


Documentation Review

Assess the adequacy and clarity of clinical documentation to support the assigned codes, identifying any discrepancies or deficiencies that may impact billing accuracy or compliance.


Audit Reporting and Recommendations

Compile audit findings into a comprehensive report, highlighting areas of improvement or potential compliance risks. Provide recommendations for corrective actions or additional training to enhance coding accuracy and documentation integrity.

Benefits of Working with TriumpHealth

Clinical Charts and Coding Audits

Experienced Specialists

Benefit from a team of AAPC-certified professionals with deep industry knowledge and experience in various medical specialties.

Data-Driven Insights

Utilize our insights to identify common coding errors, undercoding, or overcoding instances, and areas for improved clinical documentation.

Tailored Recommendations

We provide actionable feedback and tailored strategies to enhance your documentation processes, maximize reimbursement, and minimize the risk of audit findings.

Staff Education

Strengthen your team’s skills with targeted education sessions based on audit findings, aimed at preventing future documentation and coding issues.

Maximize Your Revenue. Schedule a Consultation Today!

We will help you achieve financial and regulatory compliance goals resulting in improved patient outcomes and increased revenue.