Are you at risk of a coding audit?


Doctors are sometimes too shy of billing accurately to avoid coding audits – in this case, they under-code using Level 1s and 2s of coding. There are others who wish to take a chance and view coding as a means to make more money. They over-code typically using Levels 4s and 5s. Both practices are incorrect.

Doctors using higher codes have usually been misguided by EHR vendors that excessive documentation justifies higher codes. In the pre-Obamacare era, several vendors used this line as a sales tool to justify a costly EHR purchase. Nothing can be further from truth.

Incorrect coding can put you and your practice at risk. What insurances look for are trends in coding across physicians of the same specialty in a specific region. For example, if you are a gastroenterologist in Nassau county in New York – you will be compared with other gastroenterologists in Nassau and other neighboring counties New York. This provides a comparison of you versus others like you who might be facing similar patient encounters. You can use this tool called Treatment Tracker developed by ProPublica to get a sense of the kind of information that Medicare reviews about you.


Here’s a simple method we recommend that doctors use to keep themselves in check. Analyze all your office visits across various years and curve them – insurances are typically seeking a bell curve. This can change from time to time but if you routinely are on one side of the curve then know that you might be out of the norm. There’s no way of saying whether this would put you at risk of an audit. What’s important is the real encounter that happened with the patient and whether you strongly believe that the encounter justifies a certain type of code. If you do then you simply need to store the necessary medical documentation.

Coding less out of fear and coding more out of greed are both wrong approaches to billing. Attend a sound coding class and develop a sense of coding right and incorporate a practice of storing suitable documentation that allows you to defend yourself if ever there’s an audit.


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