HIM 260 Medical Record Auditing

This course focuses on the principles and practices of auditing medical records. The course covers topics such as applying CPT and ICD 10 CM /PCS coding guidelines in audits, compliant coding, preparing an audit plan, and post-audit follow-up and communication.

Credits

4

Prerequisite

HIM 160, HIM 222, and HIM 273

Course Learning Outcomes

Upon successful completion of this course, the student will be able to:
1. Explain the importance of accurate and complete medical record documentation for clinical care, compliance, and reimbursement
2. Identify the key elements of a medical record and describe how they support the delivery of high-quality patient care
3. Analyze medical records to identify errors, inconsistencies, and incomplete documentation that could result in clinical, legal, or financial risk
4. Apply documentation guidelines for ICD-10-CM and CPT coding to ensure accurate and consistent coding and billing
5. Develop a comprehensive audit plan that includes risk assessment, sampling, and data analysis methods for effective auditing
6. Evaluate clinical documentation to identify opportunities for improvement and develop strategies to address documentation deficiencies
7. Prepare and present audit reports that effectively communicate audit findings and recommendations to stakeholders, including clinicians, administrators, and compliance officers
8. Implement clinical documentation improvement initiatives that address deficiencies and enhance the accuracy and completeness of medical record documentation