Body of Knowledge

Body of Knowledge

The Certified Medical Audit Specialist® certification examination is based on four main core curriculum domains, each domain supported by task-specific categories and sub-categories representing the scope and job responsibilities of medical auditors nationally.

AAMAS conducted two national Job Task Analysis surveys in 2004 and 2006 completed by medical auditors from all types of disciplines. Job Task Analysis (JTA) also referred to as Job Delineation Study is a systematic process designed to identify the skills, knowledge and abilities required in the performance of a task or tasks within an occupation or profession; and for medical auditors, the JTA survey confirmed the various skills, knowledge and abilities that define the scope of medical audit practice. The results of the JTA survey serve as the blueprint in the design, evaluation and content validation of the CMAS® certification examination, and became the test specification basis for the items constructed for the CMAS® examination. The JTA survey results (knowledge, skills and abilities) were psychometrically and statistically validated according to the “frequency and criticality” responses provided by medical auditor survey participants. Finally, these results serve as the empirical content specification linked to the development of the CMAS® certification examination.

Click here to download a pdf file of the core domains.

Core Curriculum Domain 01: Professional Standards and Audit Behavior (8%) 

  • 01.01.01   Participate in goal setting, strategic planning, and mission/vision development activities
  • 01.01.02   Integrate code/standards of conduct policies in performance of medical audit activity
  • 01.01.03   Establish/monitor appropriate patient access and confidential policies
  • 01.01.04   Establish/participate in enforcing expectations and systems of accountability
  • 01.01.05   Apply principles of objectivity in performance of medical audit activity
  • 01.01.06   Develop/monitor effectiveness of internal control policies
  • 01.01.07   Apply principles of independence in performance of medical audit activity

 

Core Curriculum Domain 02: Medical Audit Process and Methodology (Total = 58%) 

02.01 Investigate and Verify Charges Against Medical Record Documentation (5%)

  • 02.01.01   Inpatient Hospital
  • 02.01.02   Physician
  • 02.01.03   Outpatient Hospital
  • 02.01.04   Ambulatory Center
  • 02.01.05   SNF/LTC/Rehab

02.02 Audit Process, Work Flow and Audit Findings (19%)

  • 02.02.01   Audit Process: Plan/discuss pre-audit process
  • 02.02.02   Audit Process: Line by line bill audit
  • 02.02.03   Validate eligibility/benefits
  • 02.02.04   Apply third party payment rules
  • 02.02.05   Review/audit accuracy of UB-04
  • 02.02.06   Assign/validate ICD-9-CM codes
  • 02.02.07   Assign/validate MS DRG codes
  • 02.02.08   Assign/validate E and M codes
  • 02.02.09   Apply official coding rules
  • 02.02.10   Assign/validate revenue codes
  • 02.02.11   Audit billing/claims systems for accuracy and timeliness
  • 02.02.12   Conduct focused and target audits
  • 02.02.13   Write audit report using standard format
  • 02.02.14   Develop pre-audit procedures and tools
  • 02.02.15   Use statistically generated audit samples
  • 02.02.16   Post audit conference and discussion
  • 02.02.17   Conduct exit interview
  • 02.02.18   Review/audit accuracy of CMS 1500
  • 02.02.19   Assign/validate CPT codes
  • 02.02.20   Assign/validate APC codes
  • 02.02.21   Apply Correct Coding Initiative rules
  • 02.02.22   Assign/validate Physician Fee Schedule
  • 02.02.23   Assign/validate HCPCS II

02.03 Other  Relevant Medical Audit Responsibilities (10%)

  • 02.03.01   Update/review/maintain charge description master (CDM) 
  • 02.03.02   Provide clinical interpretation and guidance to fellow auditors and staff
  • 02.03.03   Recommend/approve/monitor use of external auditors or subcontractors
  • 02.03.04   Apply medical necessity rules in audit activity
  • 02.03.05   Apply utilization review criteria  and protocols in medical audit activity
  • 02.03.06   Apply coding rules in medical audit activity
  • 02.03.07   Apply regulatory and legislative policies in medical audit activity
  • 02.03.08   Report identified and potential quality and risk management issues
  • 02.03.09   Participate/conduct interrater reliability (IRR) and validation exercises
  • 02.03.10   Develop/update data base for tracking and trending medical audit findings
  • 02.03.11   Prepare/submit cost benefit and financial impact analysis reports

02.04. Quality Improvement Activities, Education and Training (4%)

  • 02.04.01   Develop/update/maintain/disseminate training manuals and educational materials
  • 02.04.02   Participate in education and training of staff
  • 02.04.03   Develop Quality Assurance/Improvement policies and procedures
  • 02.04.04   Monitor productivity levels of staff
  • 02.04.05   Recommend process improvement solutions

02.05. Compliance and Special Investigations (6%)

  • 02.05.01   Develop risk assessment surveys
  • 02.05.02   Conduct due diligence and compliance audits using set rules, P/P
  • 02.05.03   Prepare audit workpapers and report findings
  • 02.05.04   Develop compliance programs
  • 02.05.05   Investigate compliance reports and issues
  • 02.05.06   Recommend/monitor disciplinary and corrective action plans
  • 02.05.07   Collaborate/cooperate with external and regulatory auditors
  • 02.05.08   Monitor/apply OIG and GSA sanction list
  • 02.05.09   Interpret/apply/disseminate laws, accreditation, licensure and certification mandates

02.06. Contracts and Negotiations (2%)

  • 02.06.01   Review/write contracts
  • 02.06.02   Negotiate w/ external auditors
  • 02.06.03   Negotiate with payors

02.07. Denial and Appeals Management (3%)

  • 02.07.01   Track and review denied claims
  • 02.07.02   Write appeal letters
  • 02.07.03   Participate in denial and appeal discussion and follow-ups
  • 02.07.04   Conduct adjustments and payments
  • 02.07.05   Recommend business process rules

02.08. Health Information Management (Medical Records) (4%)

  • 02.08.01   Abstract/collect records for department indices/databases/registries
  • 02.08.02   Collect data for internal/external use (QA, UM, RM & other related studies)
  • 02.08.03   Calculate and interpret healthcare statistics
  • 02.08.04   Perform quantitative and qualitative analysis
  • 02.08.05   Monitor and enforce JCAHO standards on Health Information Management
  • 02.08.06   Evaluate software and coding systems
  • 02.08.07   Maintain record storage and filing systems
  • 02.08.08   Monitor credentialing programs

02.09. Informatics and Technology (5%)

  • 02.09.01   Email
  • 02.09.02   Word processing tools
  • 02.09.03   Spreadsheets and databases
  • 02.09.04   Graphics, flow charts and presentation tools
  • 02.09.05   Statistical applications
  • 02.09.06   Project Management tools
  • 02.09.07   Other commercial billing and auditing systems
  • 02.09.08   Homegrown systems
  • 02.09.09   Coding systems
  • 02.09.10   Antifraud software

 

Core Curriculum Domain 03: Audit Skill (Total =21%) 

03.01. Interaction and Communication (6%)

  • 03.01.01   Physicians
  • 03.01.02   Nurses and other clinical practitioners
  • 03.01.03   Senior management team
  • 03.01.04   Legal Counsel/Attorneys
  • 03.01.05   External auditors
  • 03.01.06   Regulatory auditors

03.02. Specific Knowledge and Skill Set (12%)

  • 03.02.01   Accounting/Finance
  • 03.02.02   Problem Solving
  • 03.02.03   Statistics
  • 03.02.04   Quantitative and Qualitative Analysis
  • 03.02.05   Project Management
  • 03.02.06   Programming and Configuration
  • 03.02.07   Proposal Writing
  • 03.02.08   Nursing Process
  • 03.02.09   Clinical Judgment
  • 03.02.10   Health Information Mgt. Principles
  • 03.02.11   Research
  • 03.02.12   Negotiating

03.03. Leadership and Management (6%)

  • 03.03.01   Prepare/submit budget
  • 03.03.02   Hire/recommend/terminate staff
  • 03.03.03   Develop productivity, quality control, and process improvement measures
  • 03.03.04   Conduct performance appraisals
  • 03.03.05   Develop departmental policies and procedures
  • 03.03.06   Develop strategic plans, goals and objectives for unit/dept assigned
  • 03.03.07   Participate in internal/external work groups/committees
  • 03.03.08   Supervise billers/patient accounting or claims personnel
  • 03.03.09   Supervise coding, MT or HIM personnel
  • 03.03.10   Supervise nursing or clinical staff

 

Core Curriculum Domain 04: Medical Audit Environment (13%) 

  • 04.01.01   National Healthcare Billing Audit Guidelines
  • 04.01.02   Federal and State mandated laws
  • 04.01.03   Office of Inspector General Compliance Guidance
  • 04.01.04   General Accepted Accounting Principles
  • 04.01.05   AICPA Standards
  • 04.01.06   NCQA/HEDIS Standards
  • 04.01.07   JCAHO
  • 04.01.08   HIPAA
  • 04.01.09   Medicare/Medicaid Policies
  • 04.01.10   National and Local Coverage Determination
  • 04.01.11   Medicare Integrity Program
  • 04.01.12   US Sentencing Rules
  • 04.01.13   UM/UR criteria, standards and protocols
  • 04.01.14   Sarbanes-Oxley Act
  • 04.01.15   Health Insurance reimbursement methodologies

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