Which set of guidelines do carriers use when auditing medical records?

Carriers often utilize a combination of guidelines when auditing medical records to determine the appropriateness of services provided. This means that they may review multiple sets of guidelines, which can include both federal and local policies, to ensure they are capturing the most accurate and beneficial information for their evaluations.

This approach allows carriers to provide credit for the guidelines that best support the medical necessity and appropriateness of the services billed. By considering both sets, they offer a comprehensive review that can lead to a more favorable outcome for the provider and more accurate reimbursement.

Utilizing both sets of guidelines is essential in the auditing process because it recognizes the complexities of healthcare regulations and ensures a fair assessment. Understanding that carriers are not strictly limited to one set or solely federal guidelines reflects the nuanced nature of audits in the medical billing and coding environment.