WoundReference improves clinical decisions
 Choose the role that best describes you
WoundReference logo

Internal Medical Documentation Auditing

Internal Medical Documentation Auditing

Internal Medical Documentation Auditing



According to the American Academy of Professional Coders (AAPC), quality health care is based on accurate and complete clinical documentation in the medical record.[1] Through internal audits of their medical documentation, healthcare facilities are able to determine areas that require improvements and corrections. Hyperbaric oxygen therapy (HBOT) and wound care programs, like other healthcare services, should specifically target and evaluate procedural and diagnosis code selections as determined by physician documentation. Opportunities for improvement that are uncovered through audits can then presented for education and training of clinicians and professionals who work at each healthcare service.[1]


Medical auditing is the practice of conducting periodic internal or external reviews of coding accuracy, and of having policies, and procedures to ensure the service is running an efficient and liability-free operation.[1] Internal medical auditing is a self-review, conducted internally.


The AAPC lists several reasons why healthcare facilities should conduct medical auditing, as listed in the table below[1]

Why should facilities engage in medical auditing?

  • To determine outliers before large payers find them in their claims software and request an internal audit be done.
  • To protect against fraudulent claims and billing activity
  • To reveal whether there is variation from national averages due to inappropriate coding, insufficient documentation, or lost revenue.
  • To help identify and correct problem areas before insurance or government payers challenge inappropriate coding
  • To help prevent governmental investigational auditors like recovery audit contractors (RACs) or zone program integrity contractors (ZPICs) from reaching out to the facility
  • To remedy undercoding, bad unbundling habits, and code overuse and to bill appropriately for documented procedures
  • To identify reimbursement deficiencies and opportunities for appropriate reimbursement.
  • To stop the use of outdated or incorrect codes for procedures
  • To verify ICD-10-CM and electronic health record (EHR) readiness for Quality Programs
HBOT Auditing 

The recent round of Targeted Probe and Educate (TPE) Requests from Medicare serves as a powerful warning that it is not a matter of IF a hyperbaric program HBOT documentation is audited but WHEN. Then why not be proactive and begin the process of self-auditing to identify ambiguous, deficient, or false documentation? The TPE documents provide the elements necessary for HBOT documentation to meet medical necessity requirements. See more details on TPE in the topics "Medicare Targeted Probe and Educate Protocol" and "CMS Targeted Probe and Educate for HBOT Codes 99183 & G0277".


A simplified protocol for internal medical documentation auditing is provided below [2][3][4]

Important tasks
WhenKey points (how to execute the task)Reason (why execute the task)
Define type of medical documentation that will be auditedPrior to implementing the audit process

The following will help define which medical documentation needs to be audited:  

  • Meet with the Compliance Officer to review trends within the department;
  • Review the most frequently documented procedures such as debridements, the application of cellular- and/or tissue-based products and HBOT.
  • Review claim denials. See codes in "CMS HBO Non-Emergent Denial Reason Codes and Statements"
  • Identify services offered by the program that are part of the TPE agenda, part of the Office of Inspector General Work, and part of the Comprehensive Error Rate Testing Program

In order to be cost-effective, audits should focus on documentation that support codes that are likely to bear more errors or are being targeted by external reviewers and payers.

Determine frequency of internal auditsPrior to implementing the audit process
  • Audits may be performed daily, weekly, monthly, quarterly, annually depending on the type of documentation
  • Depending on the type of patient, auditing may be based on random sampling (e.g. for established visits/ follow up patients) or systematic (for all new patients, initial consultations should be audited)
Internal audits should be a best practice initiative, embedded in the program's routine. Through frequent audits, documentation irregularities can be corrected before they result in undesirable legal and financial outcomes
Determine who will conduct the auditsPrior to implementing the audit process
  • Does the program have internal resources (i.e., staff) to allocate to audits? 
  • Does the person conducting the audits have the necessary tools/ information to check if documentation is correct? 
It is important to clearly designate who is the internal resource responsible for the audits, to ensure that audits get completed. It is important that the person(s) conducting the audit utilize the same auditing methods and tools so that results are consistent.
Identify and gather tools/resources for the auditsPrior to implementing the audit process
  • Compile tools, checklists, guidelines from payers, including the International Classification of Diseases, 10th Revision (ICD-10), and Current Procedural Terminology (CPT) codes 
  • Review the Fiscal Intermediary's website for the language that supports wound care services and medical necessity requirements
To ensure auditing efforts result in actionable, relevant findings
Perform the auditAudit
  • Audits can be conducted on computers and/or printed records. Ensure enough space and resources are available
  • Compare documentation against resources above
  • Ensure each patient’s visit is supported by a physician’s order;
  • Review the documentation for the procedure to ensure it supports the work performed;
  • Verify that the procedure documented meets medical necessity and supports the physician’s order;
  • Review the number of procedures completed within a given time frame for each patient audited (e.g., for HBOT, may check against "Utilization Review"
  • Log findings of each chart audited
Please refer to section on 'Relevance' of the audit above
Analyze results and identify deficienciesAfter each audit
  • Summarize findings and identify trends in irregularities (e.g., same provider? Same procedures? ) 
  • Check trends in irregularities and provide suggestions for improvement, based on tools/ resources gathered above
An audit creates opportunities to drive improvements, but if results are not analyzed no findings will be identified and no actions will be taken
Present results back to stakeholders After each audit
  • Findings and opportunities for improvements should be presented to stakeholders, tactfully and mindfully with the goal to educate and not retaliate
An audit creates opportunities to drive improvements, but if results are not presented, no actions will be taken
Log audit on an audit recordAfter each audit
  • Audits, name of auditor and summary of findings should ideally be logged on a spreadsheet or similar tool for tracking purposes and future reference 
Progress can be observed by retrospectively analyzing types of findings for each log
Adjust workflowsAfter each audit
  • Create and/or review the policies and procedures that support the department’s work;
  • Understand the denial management process and ensure the department is a part of this process.
  • Work with Medical Records to define “timeliness of documentation” and closing of a record;
  • Annually review chargemaster 
An audit creates opportunities to drive improvements, but if actions are not taken, improvements will not be seen


How often should self-audit occur for HBOT?

  • Wound managers, designated staff or providers should determine the frequency of internal chart auditing. Some may choose to pick a random sample of consultations and subsequent visit documentation and conduct audits monthly, quarterly, or semi-annually. With areas that are scrutinized such as hyperbaric oxygen therapy, it may be necessary to audit the HBO provider consultation note prior to initiating therapy. Thereafter, HBOT progress notes could be audited at critical points in the course of therapy, for example, treatments 1, 10, 20, 30, and 40. See topic "Utilization Review".
  • Internal audit is necessary when a program: 

Who can self-audit?

  • There is no specific qualification necessary to perform chart audits. Rather, it is important to know what content should be included in the audit and that the audit is performed at regular intervals or if a specific need arises. Billing department auditors, clinical abstractors, managers, trained staff such as a CRHN or CHT or the provider may perform internal chart auditing. Auditing of charts is time-consuming and should be unbiased. Resources such as HBO Consulting Services are available to assist the designated internal personnel with documentation audits. 

What information should be considered in an HBOT self-audit?

  • The information on this checklist was shared by WPSGHA for the hyperbaric oxygen therapy HCPCS G0277 and 99183.[5] This information can be used as a tool for internal audits of hyperbaric charts to ensure documentation is complete and accurate in the event of an external audit. See topic "HBO Documentation Checklist
  • Sections with detailed documentation requirements, templates, and checklists for each specific HBOT indication can be found within each topic of the HBO Knowledge Base. See list of HBOT indications in " HBO Treatment Indications With Protocols"


Educating providers of hyperbaric oxygen therapy and wound care about the necessary CMS requirements is imperative. To be audit-ready, the documentation, including HBO consultation note, physician orders and daily HBO progress note must meet medical necessity requirements. Self-auditing of hyperbaric charts using the documentation guidelines CMS provides will ensure that the hyperbaric documentation is audit-ready. 

Official reprint from WoundReference® woundreference.com ©2024 Wound Reference, Inc. All Rights Reserved
Use of WoundReference is subject to the Subscription and License Agreement. ​
NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.


  1. AAPC-Advancing the Business of Healthcare. What is Medical Auditing? .;.
  2. Hess, Cathy Thomas BSN, RN, CWCN et al. Managing Your Work Flow to Meet Regulations Advances in Skin and Wound Care. 2019;volume 32(7):335-336.
  3. CMS.Gov Centers for Medicare and Medicaid Services. Comprehensive Error Rate Testing (CERT) . 2019;.
  4. US Department of Health and Human Services Office of Inspector General . Work Plan . 2017;.
  5. WPS Government Health Administrators Jurisdictions: J8A, J5A, J8B, J5B et al. Checklist for Hyperbaric Oxygen Therapy-HCPCS G0277 and CPT 99183 . 2019;.
Topic 1382 Version 1.0