Medical Auditing Practice Exam 2025 – 400 Free Practice Questions to Pass the Exam

In a surgical chart audit, the focus is primarily on the accurate coding and documentation of surgical procedures and diagnoses. The ICD-10-CM code book provides the necessary codes for diagnoses, which are essential for understanding the patient's medical conditions and justifying the services rendered. The CPT® code book is crucial for coding the specific surgical procedures performed, as it contains the procedural codes needed to reflect the services accurately. The HCPCS Level II code book is important as well, particularly for coding supplies, equipment, and non-physician services relevant to the surgical procedure.

In contrast, patient satisfaction surveys serve a different purpose. They are designed to assess the patient's experience and satisfaction with care rather than to evaluate the technical accuracy of the surgical documentation. While patient satisfaction is an essential aspect of healthcare quality, it does not contribute directly to the auditing process focused on coding accuracy and compliance. Therefore, it is not a necessary resource for conducting an accurate surgical chart audit.