Scope for each practice is confirmed in the engagement agreement, including systems, payers, and queues.
Practices discover risk only when a payer asks for money back
Without a sample review, undercoding and overcoding can both hide. So can posting rules that assign denials to contractual write-offs. An internal audit habit looks at a small, recent sample while the staff still remember the encounters, and it writes the fix into the edit or the query process.
What the work includes
- A scoped sample of encounters, claims, or posted remits
- Comparison of documentation with codes and modifiers
- Review of a denial sample for miscategorization
- Review of posting for contractual versus true denial treatment
- Written findings with examples and a suggested control
- A follow-up sample after the control is in place, if the engagement includes it
How the work moves
Step 1
Agree the question
An audit of E/M levels is a different sample from an audit of posting. The question is written first so the sample can answer it.
Step 2
Pull a recent sample
Recent encounters can still be queried. Ancient samples teach history. The size is large enough to see a pattern and small enough to read the notes.
Step 3
Score against the document
Findings cite the note and the code definition. They do not cite a target revenue number.
Step 4
Install one control
Each material finding gets an edit, a query, or a posting rule. A second sample checks whether the control changed the pattern.
Operational benefits
- Risk and leakage described with examples
- Staff teaching tied to their own encounters
- Controls that can be retested
- Less reliance on a single person's memory of payer rules
Common challenges
- A small sample is not a statistical guarantee about every claim
- External payer audits use their own methods
- Findings can be uncomfortable when a favorite code is unsupported
- An audit without a follow-up sample becomes a PDF
Technology
Samples are pulled from the billing system with encounter identifiers so a reviewer can open the note. No finding is based only on a spreadsheet of codes without the record.
Where specialty changes the work
Audit focus follows risk. E/M and preventive visits for primary care. Globals and modifiers for surgery. Time for therapy and behavioral health. The method of citing the note stays the same.
Questions
Is this a certified coding audit?
No. It is an operational review. We will not describe it as a formal attestation, a financial audit, or a compliance certification.
Will findings be used to increase codes automatically?
No. If a sample shows unsupported higher levels, the fix is documentation or a lower code. If it shows supported services that were missed, the fix is charge capture.
Can you defend us in a payer audit?
We can help organize the record and explain the workflow. Legal defense and statistical extrapolation arguments belong with counsel and the practice's compliance lead.