When auditing surgical procedures, which is the first step to take?

Determining the scope of the audit is a crucial initial step when auditing surgical procedures because it establishes the framework for the entire audit process. The scope defines what will be included in the audit, such as the specific procedures being reviewed, the time frame of the documentation, and any particular criteria or guidelines that will be applied. By outlining the scope at the outset, the auditor can focus their efforts effectively, ensuring that relevant records are examined without wandering off into unnecessary areas.

Establishing a clear scope is vital for ensuring that the audit objectives are met and that the auditor remains aligned with the goals set forth, such as ensuring compliance with coding guidelines, identifying potential overbilling or undercoding, and assessing overall quality of care delivered. This step also aids in efficiently gathering the necessary documentation and ensuring that any criteria for selection are properly adhered to throughout the audit.

Once the scope is determined, other steps like verifying medical necessity, ensuring documentation completeness, and reviewing Medical Unlikely Edit (MUE) guidelines can follow, but these are more effectively approached once the audit's boundaries are clearly defined.