Physician Auditing / Documentation

PURPOSE OF AUDITS? To identify possible problems and risks before they become a problem identified by Medicare or other payer audits. Just because you were reimbursed for a service does not mean you will keep it if your documentation does not support the services performed.

Under Coding or Incorrect
Coding Can Cost You
Valuable Income!!


  1. Clean claims
  2. Fewer appeals
  3. Increased income
  4. Decreased chances of Medicare or other payer audits


According to AMA, if a practice under codes a procedure for one Medicare patient, the procedures that were coded at a higher level could be deemed Medicare fraud....so under coding as a precaution does not help.

  • Education and training programs for physicians
  • Five or more medical records per federal payer or five to ten medical records per physician
  • Establish practice standards and procedures for dealing with practice risk areas of non-compliant physicians


Consequences for over coding could include possible refunds or fines and charges of fraud and abuse. The fines are usually $10,000 per occurrence. Auditors will not stop at one occurrence.


Electronic Health Records have increased risks of incorrect documentation.
The following are areas are common errors identified by many auditors:

  • a. Unspecified diagnosis – During implementation of ICD-10-CM Medicare rule was a follows “Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family. However, a valid ICD-10 code will be required on all claims starting October 1, 2015.” As of October 1, 2016 unspecified codes will be under scrutiny and require physicians to code to the highest level of specificity.

  • b. Information Carried Forward – Providers carrying forward information is indicative of services not actually being confirmed on that day encounter and may be considered fraud and can put a provider at a high risk of errors and other possible malpractice risks.

  • c. Incomplete Documentation – History does not identify a chief complaint or incomplete information to support the medical necessity of the diagnosis. HPI must be obtained by the provider and not ancillary staff. Complete review of systems for minor problems could be considered upcoding. ROS are pertinent inquiries about the system directly related to problem(s) identified in the HPI. Examination should be based upon clinical judgement, the patient’s history, and nature of presenting problem(s). Any notations of abnormalities must be documented and elaborate of abnormal findings. Diagnosis for MDM can only be counted for the encounter if it is addressed during the encounter or has a secondary relationship to the primary diagnosis.

  • d. ABNs – The ABN allows providers to collect payment for services that not covered or has every reason to believe it will not be covered by Medicare. This can include items that are not medically necessary, supplies, and frequency or experimental services. If ABNs are not properly administered to the patient or ABN form is not properly completed, this can be a loss of revenue to the practice.

  • e. Claim Denials – Studies have shown 70% of denials can be overturned. Is your practice have a system in place to make sure appeals and redetermination are requested or insurance denials are processed? This can be a large loss to a practice if the practice has an insufficient billing department or billing service. More importantly is they are processes in a timely manner.

  • f. Time Documentation – Time can be a determining factor in selecting the level of the encounter, however documentation must support counseling and time that was performed. Documentation must identify the total amount of time of the encounter, 50% of the encounter was counseling or coordination of care and what counseling or coordination of care was performed. Example: I spent 45 minutes and more than 50% of the visit was counseling the patient about diabetes.” The documentation must identify what counseling was performed and in as much detail as possible.
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