North Carolina Board Of Chiropractic Examiners
Chart Audit Sheet
AUDIT INSTRUCTION SHEET
Required materials are the patient’s notes, complete medical record and a record of the billing history
1.
An initial baseline audit should be performed to create a primary list of goals of things that need to be fixed or
changed in the office.
2.
Enter the date the audit was performed and the name of the person performing the audit.
3.
Enter the chart number or identification code of the chart. Please do not enter the patient’s name.
4.
The practice should use a random number generator to chose five (5) files to review.
5.
Use one form to collect the data from all five files, as to make the correction process easier.
6.
The files should be reviewed for the questions contained in the audit sheet. (This questionnaire is not to be considered an all-inclusive list, but should be used to create an initial starting point of compliance activities)
7.
As the chart is reviewed, the questions on the audit sheet should be answered as shown below.
8.
After reviewing each file, please enter notes about the compliance issues in the corresponding “additional notes’
section on the last page of this audit sheet.
9.
Recommendations should be entered to start the beginning of training on issues on non-compliance along with
implementation goals.
10. The audit should be signed and dated by the auditor.
11. The audit should be filed with the practice compliance plan to include all compliance actions.
12. An additional chart audit should be repeated in ninety (90) days to measure the implementation of compliance
activities.
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North Carolina Board Of Chiropractic Examiners
Chart Audit Sheet
Audit Date:____________ Auditor:____________
File #1 _______ File #2_______ File #3_______ File #4_______ File #5_______
PAST HISTORY
REQUIREMENT
CHART 1
CHART 2
CHART 3
CHART 4
CHART 5
CHART 4
CHART 5
Symptoms causing patient to seek treatment
Family history if relevant
Past health history (general health, prior illness, injuries, or
hospitalizations; medications; surgical history)
Mechanism of trauma
Quality and character of symptoms/problem
Onset, duration, intensity, frequency, location and radiation
of symptoms
Aggravating or relieving factors
Prior interventions, treatments, medications, secondary
complaints
Relative and absolute contraindications are noted
CURRENT ILLNESS
REQUIREMENT
CHART 1
CHART 2
CHART 3
Mechanism of trauma
Quality and character of symptoms/problem
Onset, duration, intensity, frequency, location, and radiation of symptoms
Aggravating or relieving factors
Prior interventions, treatments, medications, secondary
complaints
Symptoms causing patient to seek treatment
Reported functional deficit
Patient prognosis documented in file
Documentation of assessment of complicating factors
©2008 Compliant Services & Solutions, Inc.
www.CompliantUSA.com
North Carolina Board Of Chiropractic Examiners
Chart Audit Sheet
Audit Date:____________ Auditor:____________
File #1 _______ File #2_______ File #3_______ File #4_______ File #5_______
EXAM
REQUIREMENT
CHART 1
CHART 2
CHART 3
CHART 4
CHART 5
Asymmetry/misalignment identified on a sectional or segmen-
CHART 2
CHART 3
tal level
Range of motion abnormality (changes in active, passive and
accessory joint movements resulting in an increase or decrease of sectional or segmental mobility)
Tissue, tone changes in the characteristics of contiguous, or
associated soft tissues, including skin, fascia, muscle and ligament
Listed diagnosis codes are supported by physical exam findings
CODING
REQUIREMENT
CHART 1
CHART 4
CHART 5
Subluxation diagnosis codes are listed for all areas adjusted
Subluxation diagnosis is supported by x-ray
Subluxation diagnosis is supported by PART physical exam
Secondary diagnosis codes listed for all areas adjusted
New patient E/M coding met requirements for all 3 compo-
findings with 2 required findings (1 of 2 findings must be A or
R)
nents of history, examination and medical decision making
Established patient E/M coding met requirement for 2 of 3
components of history, examination and medical decision
making
TREATMENT PLAN
REQUIREMENT
CHART 1
CHART 2
CHART 3
CHART 4
CHART 5
Recommended level of care listed in treatment plan
Specific treatment goals listed in treatment plan
Objective measures to evaluate treatment effectiveness
Date of initial treatment is listed in treatment plan
Treatment plan extended beyond four (4) weeks
©2008 Compliant Services & Solutions, Inc.
www.CompliantUSA.com
North Carolina Board Of Chiropractic Examiners
Chart Audit Sheet
Audit Date:____________ Auditor:____________
File #1 _______ File #2_______ File #3_______ File #4_______ File #5_______
DAILY NOTES
REQUIREMENT
CHART 1
CHART 2
CHART 3
CHART 4
CHART 5
History—Changes since last visit
History—System review if relevant
Exam— Exam of area of spine involved in diagnosis
Exam—Assessment of change in patient condition since last
Exam—Evaluation of treatment effectiveness
Specific segments adjusted are listed
CHART 4
CHART 5
History –Review of chief complaint
visit
All services performed are documented / Treatment plan was
followed as noted
Documentation that patient responded/tolerated treatment
MEDICAL NECESSITY
REQUIREMENT
CHART 1
Significant changes are documented in subjective complaints
CHART 2
CHART 3
CPT and ICD-9 codes are supported by documentation
Modalities performed changed as condition progressed
such as frequency and intensity of pain
Significant changes in functional deficits and objective measures
The patient’s treatment has a direct therapeutic relationship
to the patient’s condition
The duration of treatment and the frequency of the patient’s
visits were reasonable and appropriate
Rationale for use of all modalities are documented
Services provided and billed to the carrier were preventative/
maintenance care
Patient was moved from passive modalities to active
rehabilitation as acute condition became stable
©2008 Compliant Services & Solutions, Inc.
www.CompliantUSA.com
North Carolina Board Of Chiropractic Examiners
Chart Audit Sheet
Audit Date:____________ Auditor:____________
File #1 _______ File #2_______ File #3_______ File #4_______ File #5_______
X-RAY / TESTING DOCUMENTATION
REQUIREMENT
CHART 1
CHART 2
CHART 3
CHART 4
CHART 5
The provider of the X-Ray or diagnostic test was documented
Clinical findings, objective findings and documentation sup-
port the diagnostic test performed
All X-Ray reports are documented and signed by the treating
Were full spine X-Rays taken on each new patient
If repeat X-Rays were taken within 90 days of initial X-ray
CHART 4
CHART 5
physician
date, was new condition documented?
X-Rays codes billed match the X-Rays taken
COMPLIANCE ISSUES
REQUIREMENT
CHART 1
Signature of rendering physician / provider with professional
CHART 2
CHART 3
Medical records were complete and legible
Patient name and file number was included on all pages in the
Decompression and laser therapy was not billed to insurance
carriers or prior approval obtained from carrier
If no improvement in the patient’s condition were achieved,
documentation of referral to appropriate provider
Documentation that patient was given informed consent
Patients who are a beneficiary of a Federal healthcare pro-
designation (DC)
Other provider’s records requested and review of requested
records documented
ABN is on file for each date of service GA modifier was submitted to Medicare
patient’s file
Percentage of utilization of manipulation codes as follows:
98940—25%, 98941—60%, 98942—15%
gram were not given / offered free services or other inducements
An attempt was made to collect all co-insurance and deductibles
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AREAS OF NON-COMPLIANCE
CHART # 1 Additional Notes:
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CHART # 2 Additional Notes:
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CHART # 3 Additional Notes:
_______________________________________________________________________________
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CHART # 4 Additional Notes:
_______________________________________________________________________________
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CHART # 5 Additional Notes:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Recommendations:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
I certify that these recommendations have been reviewed by the compliance officer on record
for the practice.
___________________________________________
Practice Compliance Officer
Date