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APPENDIX E | Sample Audit Review Forms

To be completed for a Compliance Program Audit, either routine or random.

Compliance Audit Review Form
Upon Completion, Please Return to:
Review Date:
Review Conducted by:
Process or Procedure to be Reviewed:
New Regulation Routine Review OIG Fraud Alert
Random Review Other:
Site Location/Department(s):
Scope of Review (include sample size, with additional sheets if necessary):
Results of Review (include any attachments):
Specific Issues or Risks Identified:
Has a Work Plan Been Initiated? Yes (If yes, attach copy.) No
Resolution of Issue:

Compliance Audit Committee Standard Probe
Medical Record No.
Account No.
Date of Admission
Diagnostic and Procedural Coding
Were assigned diagnostic and procedural codes appropriate based on documentation in the medical record? Yes  No  NA
If no, is a change in DRG/APC assignment indicated Yes  No  NA
Were appropriate modifiers assigned, if indicated? Yes  No  NA
Were appropriate condition codes assigned? Yes  No  NA
Was a correct discharge status indicated? (IPs only) Yes  No  NA
Medical Necessity
Did Outpatient diagnostics meet medical necessity? Yes  No  NA
If not was an ABN obtained? Yes  No  NA
Was MD queried for additional OP diagnostic info? Yes  No  NA
Is a signed query form present in the record? Yes  No  NA
Was the observation/inpatient stay reviewed by case management for medical necessity? Yes  No  NA
Did the stay meet criteria? Yes  No  NA
If indicated, was a notice of noncoverage issued? Yes  No  NA
Did any patient type changes occur? Yes  No  NA
If yes, were they appropriate? Yes  No  NA
Was the MSP questionnaire completed? Yes  No  NA
Written order for all tests/procedures? Yes  No  NA
H & P Present/Dictated within 24 hrs of Admission? Yes  No  NA
Diagnostic test results/post procedural notes present? Yes  No  NA
Do all documented billable procedures appear on bill? Yes  No  NA
Are billed items supported by documentation? Yes  No  NA
Preop anesthesia assessment within 48 hrs of surgery? Yes  No  NA
Pre final induction anesthesia assessment within 5 min. of procedure start time? Yes  No  NA
Post op anesthesia reassessment within 24 hrs or before OP discharge? Yes  No  NA
Professional fee charges supported by doc? Yes  No  NA
See E & M and PATH audit tools for detail.
Pharmacy Billing
A. Number billed RX items on detail bill
B. Number above items documented
C. Number documented RX items not billed
D. ___ divided by ___ = ___% Billing Accuracy B + C A + C
E. Number UB 92 HCPCS codes reviewed for correct billable unit conversions
Patient Accounting
Claim Status:  PreBill  Postbill  Paid  Partial Denial  Full Denial
Reason for Denial:

$$$ Impact of Probe Findings

Hospital Error: PreBill Removed/Adj. charges ___ Added Charges ___
Post bill Overbilled ___Underbilled ___
Payor Error: Overpaid ___Underpaid ___
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