Certified Risk Adjustment Coder (CRC)

What attributes should retrospective audits include?

1. Provider signatures only

2. Supporting documentation of diagnoses

3. Provider signatures and documentation of diagnoses

4. All of the above

The correct answer is: All of the above

Retrospective audits are essential tools used to ensure the accuracy and completeness of coding and to assess the compliance of medical records with documentation standards. The correct answer encompasses every necessary aspect that a thorough retrospective audit should include. Supporting documentation of diagnoses is critical because it provides evidence that the diagnoses claimed were not only reported but also substantiated by clinical findings, treatment notes, and other relevant sources. This documentation helps verify that the coded diagnoses reflect the patient's actual health status and medical history. In addition to the supporting documents, provider signatures play an important role in the legitimacy of the documentation. A provider's signature is a formal acknowledgment that they have reviewed, approved, and verified the contents of the medical record. This formal endorsement is essential in confirming that the documentation is credible and accurate. Therefore, an audit that combines both supporting documentation and provider signatures ensures a comprehensive evaluation of the records. It confirms not only that the codes are appropriate, but also that there is clear and accountable documentation supporting those codes. Including all these attributes makes an audit reliable and effective in ensuring compliance with coding guidelines and regulations, thus ultimately improving the quality of healthcare data.