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Physician Auditing 101

As a medical biller or new coder, itís important to understand proper documentation, where the information is found as well as guidelines for proper documentation. Not only is this helpful in billing, but as a billing company owner, itís important to ensure that your clients are properly documenting the services they are asking you to bill. This class will teach the basics of chart auditing.

This course will cover Physician Auditing. Auditing is important because it will help identify coding and documentation errors. It covers History, Examination, and Medical Decision Making. At the completion of each section is a chapter review. There is a final exam at the completion of the course.

The course has five sections: Introduction, Class 1, Class 2, Class 3, and Conclusion. All three classes feature a video segment with slides. Class 1 covers history of present illness, review of symptoms, and past medical, family, and social history. Class 2 covers examination. Class 3 covers medical decision making Ė diagnosis, complexity, and risk.

This course features a glossary with terms you will need to know to complete the course, and a resources section with all the necessary documents to complete the course. The documents include the study guide, final exam terms, the chapter review questions for reference, CMS E/M Guidelines, SOAP Note, History, 95 Exam, 97 Exam, Medical Decision Making (MDM), Audit Score Sheet, and a link to AMBACode.

Upon completion of the last section, you will have the opportunity to take the final exam covering all the sections. When you've completed the final exam, you will be able to print a certificate of completion. The test scores are not recorded until you take the final exam. You must correctly answer 75% of the final exam questions to achieve a passing score. If you do not achieve a passing score, you may retake the test.

Hereís what youíll learn:

  • Principles of documentation
  • How are the levels determined by physicians and documentation?
  • What is the history
  • What is the review of systems
  • What is past medical, family and social history
  • Examination components
  • How to determine Medical Decision Making
  • ICD-10-CM Guidelines for Diagnosis
  • Common Documentation Errors
  • Signature Guidelines
  • Corrections/Addendums to Documentation
  • Guidelines are determined by Medicare but most payers including commercial use these guidelines
  • Easy to follow and understand examples (actual notes and documentation errors from real audits)
  • Plus other resources

Guidelines, and real life examples of improper documentation.

20 hours of training, including instructor lead classes, study guide, worksheets, online reading materials, and assessments

Proper documentation explained step by step by an expert coding and billing instructor

Access course for one year from date of purchase

Printable certificate of completion upon completion of course

Earn 9 CMRS continuing education credits

Who should take this course? Medical billers, medical coders, office staff and consultants Ė anyone interested in learning the fundamentals of proper documentation and basic chart auditing.

The topics listed above are covered in our Online Course but are not representative of all comprehensive subject matter covered. To learn more about this course, feel free to speak with an Association Representative at (580) 369-2700.

This course will be taken online and can only be accessed using an internet connection.

Course access will be granted immediately if purchased through the
student center. If purchased through AMBA Store or over the phone, course access will be granted the same day, if during business hours, and the next business day if purchased after hours. Your course login information will be emailed to you.

Access to this course is set for one year. Average Course Completion Time is 30-40 hours.

AMBACode Ė our coding software to look up your codes. AMBACode includes all three sets of codes plus more. Get a 28 day free trial. Using this software would replace the need for you to purchase code books.

This Course is pre-approved for 9 CEUs through AMBA

Click here to Order this Course $149

The topics listed above are covered in our Online Course but are not representative of all comprehensive subject matter covered.

AMBA Prior Approval for 

This Course is pre-approved for 9 CEUs through AMBA

Your course login information will be emailed to you.

Our courses are offered in real time access. If you choose to enroll from here, you will be given immediate access upon verification of your payment information. If you have any questions, call us at 580 369-2700 or email us

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Physician Chart Auditing Online Course