Coding and Documentation Audits

Millennium Healthcare Consulting, Inc.® (“Millennium Healthcare”) provides personalized, high-quality, cost-effective audit services. The coding and billing professionals at Millennium Healthcare are Certified Professional Coders and predominately Registered Nurses with a full range of industry expertise in clinical documentation, compliance procedures and protocols. All have passed rigorous testing and qualification requirements. As a result, Millennium Healthcare can perform audits tailored to our clients' specifications and pinpoint areas of compliance vulnerability as well as untapped revenue and optimize proper reimbursement.

Furthermore, governmental compliance is essential in today's healthcare environment. The Office of Inspector General recommends that healthcare providers perform regular periodic medical record audits to verify that they bill services correctly to Medicare. Third-party payors also conduct their own probe reviews. An effective auditing program can decrease your compliance risk and increase your peace of mind. Findings are delivered in a comprehensive written report that will help in implementing corrective action and serve as a record of the client organization's compliance efforts.


Millennium Healthcare Consulting, Inc. ® conducts an initial phone interview with the client to determine their specific goals and objectives of the coding and documentation audit reviews.

Whether the need is an annual compliance medical records review, a focused audit on an identified specific coding and billing problem or to serve as an external coding resource to the client’s internal compliance department, our chart review process involves:

  • A coding and documentation review of each chart's documentation and coding by a certified professional medical auditor.  
    1. We will review the selected medical records to verify whether the documentation supports the CPT/HCPCS coding levels reported. Areas of focus include the following:
    2. Verify the accuracy of CPT/HCPCS assigned
    3. Review level of specificity for ICD-9 codes assigned
    4. Review for charge capture (i.e. verify the services documented are reported)
  • A detailed audit report of the findings along with recommendations and cross references to coding guidelines.
  • A consultative session (either by phone or on-site) to review the individualized audit report and summary and provide training and education based on the findings.

Our chart review process follows a structured methodology designed to identify improvement opportunities through a comprehensive assessment of documentation, coding and billing. This approach identifies gaps between existing documentation processes and minimal regulatory (AMA and CMS) documentation guidelines:

Step 1 – Auditor assigned
An auditor will be assigned to your project by matching the expertise of the auditor with your specialty.

Step 2 – Chart review performed
Chart reviews are typically performed remotely. We will work with you to identify the most appropriate method to obtain access to those records selected for the review.

Step 3 – Quality Control
We work in a collaborative environment to ensure consistent application of coding documentation rules and regulations. This team approach model provides further validation that your audit findings are complete and accurate.

Step 4 – Report of Findings
Each chart review includes a detailed written report listing errors identified during the audit, potential documentation issues and potential compliance impact. Reports will also include documentation tips and improvement recommendations based upon the audit findings. If requested, for an additional fee, we can include the financial impact of the coding variances based on your State and specific Locality Medicare fee schedule.

Step 5 – Post Audit Educational Feedback
A highly recommended consultative meeting (either by phone or on-site) to review the results of the audit report, discuss key findings and provide education and training on identified areas needing improvement.