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Conducting an Internal Audit for Medi-Cal Documentation in the CalAIM Era

As healthcare providers, it is crucial to adapt to evolving regulations and documentation requirements to maintain compliance with Medi-Cal guidelines.

The recent implementation of the California Advancing and Innovating Medi-Cal (CalAIM) program has brought about significant changes, including expanded assessment domains, the use of problem lists, elimination of treatment plans, utilization of case management plan notes, and revised utilization of CPT codes. In this article, we will explore how to conduct an internal audit that considers these changes, to prepare for a outside audit in the CalAIM era.

Define the Scope and Objectives:

In light of the CalAIM changes, define the scope and objectives of your internal audit accordingly. Determine which areas of your practice's documentation processes and procedures are impacted by CalAIM, such as expanded assessment domains and the use of problem lists. This will help you focus your audit efforts and ensure a comprehensive evaluation of compliance with the new requirements.

Develop an Audit Plan:

Develop an audit plan that aligns with the CalAIM changes and covers the relevant aspects of your practice. Consider the expanded assessment domains and ensure that your audit plan includes a review of documentation related to these domains. Allocate resources and assign responsibilities to team members who will be involved in the audit process, including those with expertise in case management plan notes and revised utilization of CPT codes.

Collect Sample Documentation:

Gather a representative sample of patient records that reflect the CalAIM documentation changes. Ensure the sample includes documentation related to expanded assessment domains and the use of problem lists. This sample should represent a variety of services provided and cover different healthcare professionals involved in the care process. Utilize automated tools or software to streamline data collection, focusing on capturing relevant information.

Review Documentation for Compliance:

Thoroughly review the collected documentation to assess compliance with the CalAIM documentation changes. Pay particular attention to the expanded assessment domains, ensuring that all required information is documented accurately and comprehensively. Evaluate the use of problem lists in patient records and confirm that they align with the new requirements. Review case management plan notes for completeness and adherence to guidelines.

Analyze Findings and Identify Areas of Improvement:

Analyze the findings from the review process, identifying areas that require improvement to comply with the CalAIM changes. Determine the root causes of any compliance issues or deficiencies and document them. This analysis will help you pinpoint areas that need attention, such as training on expanded assessment domains, problem list documentation practices, and the appropriate utilization of case management plan notes and CPT codes.

Implement Corrective Actions:

Develop a plan to address the identified compliance issues based on the CalAIM changes. Implement corrective actions, such as updating documentation policies and procedures to incorporate expanded assessment domains, problem lists, and revised utilization of case management plan notes and CPT codes. Provide staff training and education on the new requirements and ensure their understanding of the revised documentation practices.

Monitor and Follow-Up:

Establish a process for ongoing monitoring and follow-up to track the progress of implemented corrective actions. Regularly review documentation practices and conduct periodic internal audits to verify sustained compliance with the CalAIM changes. Continuously assess the accuracy and completeness of expanded assessment domain documentation, problem lists, case management plan notes, and the utilization of appropriate CPT codes.


Conducting an internal audit that considers the CalAIM documentation changes is essential to ensure compliance with Medi-Cal guidelines. By defining the scope, developing an audit plan, collecting a representative sample, reviewing documentation for compliance with expanded assessment domains, problem lists, case management plan notes, and appropriate CPT code utilization, analyzing findings, implementing corrective actions, and establishing monitoring mechanisms, you can effectively prepare your practice for a Medi-Cal documentation outside audit in the CalAIM era. Adapting to these changes not only ensures compliance but also promotes accurate and comprehensive patient care documentation. Stay proactive, stay compliant, and continue providing high-quality care to your patients while adhering to the evolving requirements of CalAIM.

Disclaimer: This article is for informational purposes only and should not be considered legal or professional advice. Consult with a healthcare attorney or compliance expert for specific guidance related to your practice and the requirements of your state or jurisdiction.

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