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Documentation Tip of the Week: Tips for Avoiding an Audit

Posted on Wed, Nov 04, 2015
Documentation Tip of the Week: Tips for Avoiding an Audit

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD


  • Official coding guidelines support coding a diagnosis that is only documented once in the medical record. However, auditors are increasingly denying diagnoses that do not flow consistently through medical record to include the discharge summary.

  • While it is not necessary for a physician to document the criteria he or she used to make the diagnosis, it will reduce the potential for denial.

  • Conflicting documentation between different providers increases the likelihood of denial.

  • Whenever possible, the attending physician should clarify any inconsistent documentation.


Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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