Level 2: Advanced Specialist

Audit Preparation & Internal Review

Master internal audit processes and prepare for MAC audit success

Learning Objectives
  • Conduct effective internal audits to identify compliance risks before MAC review
  • Recognize high-risk documentation patterns that trigger MAC audits
  • Implement corrective action plans for identified deficiencies
  • Develop systematic processes to prevent future audit findings
  • Understand MAC audit priorities and focus areas
Internal Audit Framework
Systematic approach to identifying and correcting compliance risks

1. Audit Frequency & Sample Size

  • • Monthly: Review 10-15 charts (5-10% of admissions)
  • • Quarterly: Comprehensive review of 25-30 charts
  • • Focus areas: High-CMG cases, Tier 1 comorbidities, FIM outliers

2. Priority Audit Elements

HIGH RISK (Review 100%)

  • • Tier 1 comorbidity documentation
  • • FIM scores vs. functional documentation
  • • Physician documentation quality

MODERATE RISK (Sample review)

  • • Therapy minutes and documentation
  • • Medical necessity criteria
  • • Discharge planning documentation

3. Common Audit Findings

  • Tier Coding Errors (40%): Unsupported Tier 1 codes, wrong tier assignment
  • FIM Discrepancies (30%): Scores don't match nursing/therapy notes
  • Documentation Gaps (20%): Missing physician assessments, incomplete H&P
  • Timing Issues (10%): Late IRF-PAI completion, delayed physician documentation

4. Corrective Action Process

  1. Identify: Document specific finding and chart reference
  2. Analyze: Determine if isolated incident or systemic pattern
  3. Correct: Query physician if appropriate, correct coding if needed
  4. Educate: Provide targeted training to prevent recurrence
  5. Monitor: Track improvement in subsequent audits

5. MAC Audit Red Flags

Patterns that trigger MAC audits:

  • • Unusually high percentage of Tier 1 comorbidities
  • • Consistently high CMG assignments compared to peer facilities
  • • Pattern of FIM scores at specific thresholds (e.g., always 12-13)
  • • Sudden increase in specific diagnosis codes
  • • High readmission rates or early discharges
Module Quiz
Test your knowledge of Audit Preparation & Internal Review concepts

8

Questions

85%

Passing Score

~12

Minutes

Quiz Instructions:

  • Answer all 8 questions to complete the quiz
  • You must score 85% or higher to pass
  • You can navigate between questions before submitting
  • Review explanations for all questions after submission
  • Retake the quiz as many times as needed to pass