Conducting regular audits ensures coding compliance, reduces denials, and maximizes revenue. Here’s how to perform an effective audit:
🔹 Step 1: Define Audit Scope
✔ Sample Size: 5-10% of claims (stratified by provider/service)
✔ Focus Areas:
- E/M Leveling (99202-99215)
- Procedure-Diagnosis Linkage
- Modifier Usage (e.g., -25, -59)
- Documentation Completeness
🔹 Step 2: Gather Documentation
- Medical Records (progress notes, operative reports)
- Charge Sheets (verify billed services match documentation)
- Payer Policies (LCD/NCD for medical necessity)
🔹 Step 3: Verify Key Elements
| Checkpoint | What to Look For |
| ICD-10 Specificity | Avoid unspecified codes (e.g., R51.9 → R51.0) |
| CPT® Accuracy | Correct code selection (e.g., 99213 vs. 99214) |
| Modifier Necessity | Proper use of -25, -59, etc. |
| Medical Necessity | Diagnosis supports procedure |
🔹 Step 4: Identify Errors
✔ Under/Overcoding (e.g., billing 99215 for a straightforward visit)
✔ Unbundling (billing components separately that should be bundled)
✔ Missing Documentation (no signed orders or progress notes)
🔹 Step 5: Take Corrective Action
- Provider Education – Address documentation gaps
- Coder Retraining – Clarify coding rules
- Process Adjustments – Implement pre-billing audits
🔹 Best Practices
✔ Audit Quarterly (minimum)
✔ Use Audit Templates for consistency
✔ Benchmark Against Industry Standards (e.g., MGMA metrics)
