Separate the Review Questions
A service may be coded correctly and still fail coverage or medical-necessity requirements. An audit-ready review separates code accuracy, documentation support, policy requirements, and utilization considerations instead of treating them as one issue.
1. Coding Accuracy
Confirm that the reported diagnosis, procedure, units, and modifiers accurately represent the documented service.
2. Documentation Support
Verify that the record supports the service performed, clinical circumstances, frequency, and level of care.
3. Coverage Requirements
Review applicable payer policy, benefit limitations, prior authorization, and coverage criteria.
4. Clinical Rationale
Determine whether the record explains why the service was reasonable and necessary for the patient's condition.
5. Frequency and Units
Validate that the number of services, units, and timing are supported by the record and applicable policy.
6. Audit Trail
Document the source reviewed, issue identified, decision reached, and corrective action when applicable.