Medical Auditing Practice Exam

What additional resources are required to conduct a focused audit for a general surgeon?

1. Just the CPT codebook

2. Medical terminology book and surgical definitions

3. Patient satisfaction surveys

4. Financial statements

The correct answer is: Medical terminology book and surgical definitions

To conduct a focused audit for a general surgeon, having a medical terminology book and surgical definitions is crucial. This is because a focused audit requires a thorough understanding of the specific procedures performed by the surgeon and the language used within that specialty. A medical terminology book helps auditors interpret clinical documentation accurately, allowing them to identify the appropriateness of coding and billing practices. Surgical definitions provide context and clarification on the procedures performed, enabling the auditor to assess the necessity and quality of the services provided. While the CPT codebook is essential for understanding procedure codes, it does not encompass the broader context of the surgical practices or the specific language used in the clinical notes. Similarly, patient satisfaction surveys and financial statements, while valuable in different auditing contexts, do not directly support the detailed clinical understanding necessary for performing a focused audit. Therefore, the additional resources of a medical terminology book and surgical definitions are foundational for accurately assessing and ensuring compliance with coding practices relevant to a general surgeon's work.