What to Do During a Coding Audit
A coding audit is not an accusation—it’s a quality check to ensure accurate coding, documentation, compliance, and proper reimbursement. Here’s how to navigate one effectively.
**1. Stay Calm, Professional, and Compliant
Audits are routine.**
Avoid defensiveness. Instead:
Respond professionally
Follow your organization’s policies
Avoid altering documentation after the fact
Your goal is clarity, accuracy, and transparency.
2. Review the Audit Scope Carefully
Understand what the auditors will evaluate:
What time period is being reviewed
Type of services (E/M, surgeries, diagnostic tests, etc.)
Number of records
Whether it’s internal, payer-initiated, or government
Knowing the scope prevents unnecessary work and helps you focus.
3. Gather All Relevant Documentation
Prepare everything the auditor needs:
Medical records
Provider notes
Coding worksheets
Encounter forms
Policies and procedures
Prior coding guidelines (if historical dates are involved)
Ensure documents are complete, legible, and consistent.
4. Do NOT Modify Medical Records
Once a record is finalized, it must remain untouched.
Never backdate, change, or add documentation unless following formal amendment procedures.
Improper changes can be considered fraud.
5. Ensure HIPAA Compliance
Only send:
The minimum necessary information
Records through secure channels
Double-check that no extra PHI is included.
6. Answer Questions Clearly and Factually
When auditors ask for clarification:
Stick to facts
Reference guidelines, not personal opinion
Provide direct, concise explanations
Do not speculate
If you don’t know the answer, say you’ll verify and follow up.
7. Be Prepared to Justify Your Coding with Official Sources
You may need to support your coding choices using:
ICD-10-CM/PCS official guidelines
CPT®/HCPCS guidelines
CMS policies (NCCI edits, LCD/NCD)
AMA instructions
Facility-specific policies
Always support findings with published, authoritative sources.
8. Listen to Auditor Feedback Without Arguing
You may disagree with findings—wait until you review them thoroughly.
Instead of debating:
Take notes
Ask clarifying questions
Request the rationale or guideline used
Professionalism helps the process go smoothly.
9. Conduct an Internal Review of Every Audit Finding
Before accepting results:
Re-check each flagged code
Compare against documentation
Validate guidelines
Confirm sequencing, specificity, and coding rules
Sometimes auditors are wrong; sometimes they spot overlooked errors.
10. Meet With Providers If Documentation Is the Issue
If discrepancies relate to:
Missing details
Ambiguous documentation
Incomplete notes
Schedule a provider education session.
Use:
Examples
Clear, concise guidance
Specialty-specific tips
Avoid blame—focus on improving accuracy.
11. Correct Verified Errors
Once findings are validated:
Correct claims according to payer rules
Follow re-billing procedures
Log corrections for compliance reporting
Never resubmit claims without proper authorization.
12. Implement Action Plans to Prevent Repeat Errors
From the audit results:
Identify trends
Conduct coder education
Update templates or workflows
Strengthen internal audits
Create documentation checklists
The goal is continuous improvement.
13. Document Everything
Keep detailed audit records:
Audit scope
Records reviewed
Findings
Corrections made
Education provided
Action plans
This helps demonstrate compliance if questioned later.
Quick Summary
During a coding audit:
Stay calm and follow procedures
Provide required documentation
Never alter records
Justify coding using official sources
Review and validate all findings
Implement corrective actions
Document the entire process
Learn Medical Coding Course in Hyderabad
Read More
ICD-10 Guidelines Every Coder Must Follow
The Importance of Accurate Documentation
Avoiding Fraud in Medical Billing & Coding
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