What Triggers a Coding Audit?


While a staff member may aid with coding, the physician — who is accountable to the government and other payers — must review the codes for accuracy prior to submitting them for billing. Watch for these red flags in your practice’s coding habits:

  • Within a group setting, inconsistent coding among partners.

  • Excessive use of a code.

  • Coding level 5 services and not preventive medicine codes for annual physicals.

  • Upcoding on stable chronic conditions.

  • Missing physician signatures for lab and/or test results ordered by a physician assistant, nurse practitioner, or physician.

  • Use of words such as “maybe,” “perhaps,” “probably,” or “rule out” instead of signs and symptoms.

  • Use of symbols or shorthand. (Be sure to have a list of what the symbols or shorthand means in your office. Negative symbols without elaboration are not considered sufficient documentation.)

  • Lack of specificity about what you are reviewing. (Review of systems as unremarkable is insufficient data to support that a review was completed.)


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