Medical record audit Medical record audit: how do you send gaps back to the care team?
Loop for returning the documentation gaps found in a medical record audit to the care team. Own elaboration based on CFM Resolutions 1,638/2002 and 2,217/2018 (Code of Medical Ethics, art. 87) and Cofen Resolution 736/2024 (art. 8), Brazil. Produced by Accrua.
See in the guide: Medical record audit: what must be documented so the claim isn't deniedOn-site vs. electronic claims audit On-site vs. electronic audit: advantages and risks of each model
Where each health plan audit model enters the claim path. On-site audit acts until the claim is released, with the medical record reviewed in the hospital; electronic audit acts after the TISS batch protocol. Source: CFM Resolution 2,448/2025, art. 10; Cofen Resolution 720/2023, annex, item VI; ANS — TISS standard, Organizational Component 202609, item 33. Produced by Accrua.
See in the guide: On-site vs. electronic claims audit: advantages and risksClinical documentation for billing (CDI) How does a clinical documentation program work in the hospital?
Source: Federal Council of Medicine (CFM) — Resolution 1,638/2002 (arts. 3–5) and Brazilian Code of Medical Ethics (CFM Resolution 2,217/2018, arts. 80 and 87). Practical adaptation: no Brazilian rule defines a CDI program. Produced by Accrua.
See in the guide: Clinical documentation for billing (CDI): what physicians need to recordHospital billing specialists and auditors Hospital billing specialists and auditors: career paths, from charge entry to revenue management
Three illustrative career paths in Brazilian hospital billing and claims audit. Legal requirements appear in the boxes; the sequence of roles is an example, not an official job ladder. Source: Law 12,842/2013, art. 5, II; Law 7,498/1986, art. 11, I, "h"; CFM Resolution 2,448/2025, art. 8; Cofen Resolution 720/2023; MTE — CBO 2002. Produced by Accrua.
See in the guide: Hospital billing specialist: what they do, training, skills and auditor careerHow to negotiate with the payer's auditor Negotiating with the payer's auditor: how do you record what was agreed?
Sources: ANS — RN 503/2022, arts. 5 and 14; TISS Standard, Organizational Component 202609, items 51 and 55; TUSS table 38. The contract appeal deadline keeps running during the negotiation. Produced by Accrua.
See in the guide: How to negotiate with the payer's auditor: technique, documents and minutesPre-audit of every claim How the pre-audit flow works
Two-layer pre-audit flow: automated rules on 100% of claims and human review of flagged claims. Prepared from the TISS standard, version 202609 (ANS). Produced by Accrua.
See in the guide: Hospital claim pre-audit: how to review 100% without slowing billingProspective, concurrent and retrospective audits Prospective, concurrent and retrospective audits, side by side
Source: CFM Resolution 2,448/2025 (statement of reasons and art. 10, IV); market practice. The three types of audit by point in the episode of care. Produced by Accrua.
See in the guide: Types of audit: prospective, concurrent and retrospective, and when to use each
