Coding audit
Paid Does Not Mean Protected: Five Questions to Audit
A clean payment today does not guarantee that the record could defend that payment during a later review.
One of the most expensive assumptions a practice can make is that a paid claim is automatically a compliant claim. Payment confirms that a payer processed the claim. It does not necessarily confirm that every element would withstand a later medical review.
1. Does the record support the service that was billed?
An auditor should be able to follow the clinical story from the presenting problem through the assessment, plan, and service selected. The record should make the provider's work understandable to a qualified reviewer who was not in the room.
2. Is medical necessity clear?
Documentation should explain why the service was reasonable and necessary for this patient on this date. A diagnosis code alone may not communicate the severity, work, or circumstances that drove the service. CMS medical review guidance is one reason internal audits should examine both the code and the supporting record.
3. Would the code selection stand on its own?
Review E/M level selection, procedure descriptions, diagnosis specificity and order, and the relationship between diagnoses and services. An internal coding audit evaluates the work already performed; it does not require replacing the practice's current coder or billing team.
4. Are modifiers and edit pairs defensible?
A modifier should communicate a supported circumstance, not merely force payment. CMS explains that NCCI procedure-to-procedure edits are designed to prevent inappropriate payment for services that generally should not be reported together, with limited exceptions when an appropriate modifier is clinically supported.
5. Is this an isolated error or a repeated pattern?
One finding may call for individual feedback. A repeated finding may indicate a template, training, workflow, or oversight problem. Audit results become valuable when the practice trends them, assigns ownership, educates the team, and measures whether the pattern improves.
Start with a focused sample. Look for patterns across documentation, medical necessity, code selection, modifiers, and payer policy. Then turn the findings into targeted education rather than asking the team to “be more careful.”
Primary CMS references
Medicare Program Integrity Manual Medicare NCCI Policy Manual
This article is general educational information and is not legal advice, payer-specific coding advice, or a substitute for reviewing the rules that apply to a particular claim.