Key takeaways
- Start with high volume and high value codes, and include each provider.
- Check that documentation supports the code, units, and modifiers.
- Use findings to update templates, scrubber rules, and provider feedback.
A coding audit compares what was billed with what was documented. Done regularly, it catches errors before payers do, finds money left on the table, and gives providers clear feedback on documentation. It does not need to be a large project to be useful.
Pick the right sample
- Start with your highest volume codes and your highest value services.
- Include each provider, so feedback is fair and specific.
- Add claims from your top denial reasons.
- Use a sample size you can review well, then repeat on a schedule.
What to check first
- Documentation supports the code. The note should describe what was done, why, and for how long when time matters.
- Evaluation and management levels match the documented medical decision making or time, under current guidelines.
- Diagnosis codes are specific, current ICD-10-CM codes that support the procedure.
- Modifiers are used correctly and supported by the note.
- NCCI edits are respected, so bundled services are not billed separately without support.
- Units match documented time or quantity.
- Payer specific rules are followed for your top payers.
Look for both directions
Audits often focus on overcoding, but undercoding matters too. Providers who code conservatively out of caution leave legitimate revenue unbilled. A fair audit reports both, with examples.
Turn findings into action
- Share results with each provider using real examples from their notes.
- Update templates or charge entry rules where the same error repeats.
- Add scrubber edits for errors that can be caught automatically.
- Re audit the same areas later to confirm the fix worked.
Internal vs external audits
An internal team knows your workflow. An external reviewer brings fresh eyes and no habits to defend. Many practices use both: regular internal checks, with an outside review from time to time or when denials rise.
If an audit finds possible overpayments, take advice on how to handle them. Payers and federal programs have rules about reporting and returning overpayments.
A quick example
An audit of follow up visits finds one provider consistently selects a lower visit level than the documentation supports, while another selects a higher one. Each receives feedback with examples from their own notes, and the practice updates its visit template. A follow up audit a few months later shows both providers closer to what the documentation supports.
Questions to ask your team
- Which codes deny most often, and why?
- When did we last review each provider's coding?
- Do our templates prompt for the details payers ask for?
Keep the audit fair and useful
Use the same written criteria for every chart, record who reviewed it, and note the guideline or payer policy behind each finding. When a finding is unclear, discuss it with the provider before it goes into the report. Audits that feel fair get acted on. Audits that feel like blame tend to be ignored.
Where Afiable helps
Afiable provides ICD-10, CPT, and HCPCS coding with payer specific checks, plus coding audits with clear findings and feedback for providers. Book a free audit and we will review a sample of claims and show you what to check first in your practice.
Questions practices ask
How often should a practice audit coding?
Many practices review a small sample regularly, such as quarterly, and add a focused review when denials rise or rules change.
Should providers see their audit results?
Yes. Specific examples from their own notes are the fastest way to improve documentation and coding.
This article is general information for practice owners and managers. Payer policies and regulations change, so confirm current rules with each payer before acting.