What is the first step in auditing E/M services?

The first step in auditing E/M (Evaluation and Management) services is to determine the scope of the audit. This initial phase is crucial as it outlines the framework and objectives of the audit process. Establishing the scope enables the auditor to define the parameters of the review, including which encounters or records will be assessed, the time frame, and the specific types of E/M services being audited.

By determining the scope of the audit, the auditor is able to focus their efforts effectively, ensuring that all relevant areas are covered and that the audit process is efficient and organized. This foundational step ensures that subsequent actions, such as reviewing the medical records for correctness, verifying the medical necessity of services, and compiling a report of findings, are all aligned with the predetermined objectives of the audit.

In contrast, reviewing medical records, verifying medical necessity, and compiling a report are steps that follow the establishment of the audit's scope. Each of these subsequent actions relies on having a clear understanding of what the audit is intended to achieve, emphasizing the importance of this first step.