A Useful Guide On How To Avoid Coding Audits

Private payers and government payers tend to focus on conducting audits in order to find out all of the abusive or fraudulent activities that might take place during the course of medical coding and billing. Being a medical provider, getting the right amount of reimbursement after providing all of the services is important. But it is also of key importance to avoid all of the inappropriate medical billing practices in order to stay out of trouble and maintain a healthy financial status for your organization. It is important to understand all of the medical coding errors that can occur and how you can avoid them.

What Is A Coding Audit?

Medical coding audits should include a select sample of patient encounters as coded and billed.

Medical coding audits refers to the external or internal review that comes from a medical organization’s billing and coding practices through proper conduct of reviewing the medical records for a patient. The audits of a medical record tend to target and also evaluate the diagnosis and procedural code selection. 

There are a number of different factors that are considered by the coding auditor:

  1. Assessing the real use of the CPT codes
  2. Looking for the incorrect or missing use for all the modifiers
  3. Determining the veracious places for all the services
  4. Identification of the support documentation trends, accuracy and other deficiencies 
  5. Detecting any incorrect diagnosis that does not demonstrate any kind of medical necessity
  6. Determining whether the services are necessary and reasonable
  7. Identifying any cluster or bundling issues (LMRP and CCI edits)
  8. Verifying the support documentation is sufficient or not in order to describe the needed things when it comes to service provided to the patient


All of the results that come out of the audits get discussed in relation to the medical coding accuracy which helps in avoiding all of the medical coding errors. The constant accuracy rate of either 95% or even higher for all the medical providers is always recommended by the OIG (HHS Office of the Inspector General). 

What Makes Coding Audits So Important?

How to Avoid a Medical Coding Audit?

One of the requirements for compliances is to conduct one annual medical billing auditing according to the HHS Office of the Inspector General. Outsourcing medical billing companies take care of this aspect quite nicely. The OIG and the Center for Medicare and Medicaid Services (CMS) tend to encourage all of the medical providers so that they can regularly review the medical coding with the aid of a professional medical coding service

Many of the regular medical billing and coding audits tend to provide a lot of advantages that help in improving your medical practice. 

  1. Ensuring that your medical coding practices have up-to-date and acceptable standards
  2. Identifying the different areas of the revenue that is lost which mainly occurs due to miscoding practices.
  3. Comparing the coding practices with other medical peers
  4. Identifying the different areas for all the medical compliances concerns


No matter what kind of score your medical audit has, remember that constant improvement should always be the ultimate goal. The process of medical audit allows for an opportunity wherein your medical practice can identify and therefore prevent the necessary compliance. It also helps in avoiding the issues with payment and helps in the improvement of the medical staff. 

Ways To Prevent Medical Coding Audit

There are different ways that can help in the prevention of medical coding audits. 

  1. Precise Documentation: The part where the majority of the medical providers tend to fail when it comes to medical documentation is when it comes to the history of the patient’s illness. Relying solely on the patient for crucial information can lead to exclusion of key pointers which again leads to the tasking of the wrong codes.
  2. Coding errors: Checking whether the assigned codes by the EHR is accurate and precise or not is quite important. Experts tend to recommend that the medical professionals follow – subjective, objective, assessment and planning which is abbreviated as the SOAP approach. This helps in providing the proper guideline to document the medical case and also provide the right kind of codes. The narrative provided by the patient on the present day will help with the documentation process and it must not be copy-pasted from only the previous visit.
  3. Avoiding indiscrimination when it comes to the use of EMR cut: When you use the EMR cutting and pasting option in order to copy all of the information that pertains to a single visit, it could lead to many errors. This could seriously affect the care provided to the patient. Shortcut methods such as these could lead to medical coding errors which can, in turn, affect the reimbursement process.
  4. Paying close attention to the element of time: If the time that is spent with the inpatient falls within the area service range of the chart of the patient, then there is nothing to fret about. But when the extra time is being concerned with the patient, justifying the time is important. Medical providers might just spend extra time when it comes to explaining the risks, treatment options, benefits, counseling, patient education and much more.
  5. Performing mock audits: If you want your medical organization to succeed, performing random mock audits is the way to go. Not only can it give your organization that extra push but also helps in providing the necessary awareness from the medical coding audits. The mock coding audit process can help in the identification of the problems such as over codes or even under codes. Performing a mock audit will allow you to look at the coding or billing inaccuracies, duplicate claims or the absence of support documentation.


When the volume of patients rises the focus on patient care also rises which makes the medical professionals rely more on the medical billing and coding auditor. Through outsourcing medical billing companies, the focus can be shifted to making cleaner claims, lessening the workload and improving the overall efficiency of the office. Medical coders are experienced in ICD and CPT codes thereby ensuring precise coding and fulfilling the process of reimbursement for the medical organizations, and this is where a company like Synergy HCLS can help you out.