Coding audits 101: How physicians can prepare

Author: Abdul J. Roberts, Esq., Jim Tudor, PCA, CPC

You’ve received a request for medical records from a payer, who is going to conduct an audit on your claims. Your Electronic Health Record (EHR) system is excellent, the notes are voluminous, your providers are well-versed at coding. If anything, you under code! You provide excellent care for your patients and achieve great outcomes. No one has ever given you any trouble before.

Nothing to worry about, right?

Several months pass, and you get a letter from the payer. It’s the results from your audit. You open it up, and see:

“…medical necessity not supported…”;
“…notes are cloned…”;
“…records include conflicting data.”
It also says you owe an astronomical amount of money due to “overpaid claims”, and they are putting you on pre-payment review until things improve.

What just happened? Why are they doing this? Can they even legally do this? Welcome to the world of billing and coding, where black and white is often eclipsed by gray. Where the “obvious” is rarely so, and where sometimes, less is more.

Below are recent trends in medical audits and what physicians can expect with the the U.S. Centers for Medicare and Medicaid Services’ (CMS) changes in 2021 to the documentation of Evaluation and Management (E/M) codes.

Most providers have an EHR system where they fill in pertinent patient information, as prompted by the EHR system. Is there anything they need to be on the lookout for?

An EHR system is supposed to make your life easier. It provides accurate, up-to-date information about the patient. Its purpose is to facilitate coordinated access and information sharing among physicians. It helps providers more efficiently diagnose patients, reduces errors, provides safer care, facilitates quality. And, by the way, it does a bang-up job of capturing essential billing elements. Pop in the right template, maybe tweak it a little, and you’re good to go.

So, where do things go astray? Well, to understand how something like this can happen, you first need to understand how the patient’s medical record influences medical necessity. Per CMS, medical necessity is the overarching criterion for payment. Inaccurate information in the chart, especially when carried forward from a previous service date or entry without necessary editing, often does not afford an auditor the ability to understand if you needed to see that patient, perform that test, order that script, etc.

Often the information obtained from a patient has not changed from the prior visit. So, what is the potential problem with just carrying information forward?

Auditors across the nation, both private and public, love to deny claims based on allegations that the provider simply copied and pasted prior notes. “Copy/paste” type operations that occur without needed modifications to content is a process infamously known as “cloning’’. And that doesn’t just refer to the entire progress note as a whole; it can refer to pieces of a progress note that are inaccurate. Those pieces could be integral to billing a distinct procedure, or a crucial element associated with an office visit code. If one or more pieces never, or almost never, change from one visit to the next, the auditor doesn’t know if the information simply didn’t change, or may have changed but just wasn’t edited.

Lately, auditors seem to assume the latter.

Is there anything else that auditors look for when they believe a note is cloned?

The presence of conflicting information is another giant red flag. If the history indicates the patient has severe dementia, but the review of the systems template indicates “All systems were reviewed and negative”, well, that could be a problem. One error of this nature can lead to a reviewer to cast aspersions on the integrity of your note. “What else could be wrong with this chart?”, thinks the auditors.

Truth be told, these are usually just innocuous mistakes that do not represent any intent to commit billing fraud. The payers don’t see it that way. They don’t know if you forgot to revise that review of systems because you’re up until 11:30pm signing off on your notes, or if you’re trying to pad the record with billing elements. All they know is there is a conflict or redundancy which could represent something fraudulent.

Are there any other potential pitfalls that are low-hanging fruit for auditors?

Another pitfall that may come back to haunt you is the overstuffed progress note. This occurs when the sheer quantity of the displayed items seems wildly disproportionate to the nature of the presenting problems.

Taken at face value, it would seem that a single, self-limiting medical condition would not normally warrant a complete review of past medical, family, and social history, a full review of systems and comprehensive exam. Although there may be times when circumstances do require a more intensive evaluation than meets the eye, the payers expect this would be the exception, not the norm.

All of this leads to a presumption that the information in your charts is questionable. Once that notion is planted in an auditor’s head, it colors their perspective. If you happen to be a “high volume” provider with disproportionately more billing of any particular code or modifier, the notion that there “must” be something disingenuous going on becomes solidified. This thinly veiled ethical challenge can be insulting and infuriating to hard-working providers who would never, in a million years, intentionally submit an unsupported health claim.

Will providers have to completely change the way they document Medical Necessity?

A gift horse arrived on January 1, 2021, by the name of the new 2021 E/M guidelines. These are new rules, created by the AMA and adapted by CMS and other payers, for outpatient office visit codes (codes 99202-99215 only).

The guidelines effectively remove those pre-existing requirements to “quantify” the history and physical examination: you no longer need to worry about having “enough” of that ROS anymore. However, you should continue to document those aspects of history and exams that lend support to your clinical decision-making and any tests or treatments ordered. E/M coding has historically been associated with EHR misuse, in part due to the confusing and onerous documentation requirements imposed by the CMS.

The new rules allow physicians to document the most salient points relevant to the medical decision making, or time spent. It is coding, so there are charting nuances you still need to know, but this is an enormous step in the right direction.

Is there anything else providers should keep in mind when documenting Medical Necessity?

Another very simple rule to bear in mind is: change what changes. Your notes should always have an interval history of present illness (HPI). The history of the problem is what it is, but there is usually something unique to say about the patient’s status covering the period between the last appointment and the current one.

Also, make a point to label it “Interval HPI”, don’t blend it in with the other history because that combination of new and old data sometimes doesn’t sit well together. You want unique documentation for each encounter, and it should stand out in your progress note. Taking the Interval HPI concept one step further, understand that encounter-specific charting is king. With the E/M changes comes a flexibility that has not existed in many years.

The rigidity of cookie-cutter, awkward appearing templating is, from a billing standpoint, now inferior to an old-school 1985-ish free text paragraph or two (yep, I remember those).

Everything has come around full circle. Less is more.

This sounds like a good development that will benefit providers. Do these documentation changes apply to all Current Procedural Terminology (CPT) codes?

To be clear, the E/M documentation changes do not apply to all CPT codes. Certain services, such as wellness visits, chronic care, transitional care, etc., require more rigidity in capturing essential elements. However, you do want to infuse encounter/patient specificity into those templates too. Despite the redundancies, you still need to personalize those notes to render them unique to the patient. A little TLC goes a long way.

Any parting pieces of advice for providers going forward based on the changes to the E/M Guidelines?

Spend an extra five to 10 minutes proofing those notes before you close them. As my mom once said, “An ounce of prevention is worth a pound of cure”. The immense benefits of such diligence can truly be worth its weight in gold.

In the unfortunate event that you do receive one of those nasty overpayment demand letters someday, don’t acquiesce without conducting an analysis first. Let’s face it: they call them “procedure” codes because there are commonalities. Certain things may not change, or change much, from one service date to another. If you’ve changed the things that change, and still got dinged in an audit, there may be sufficient basis to challenge the results.

There is no requirement to rephrase verbiage in your charts just for the sake of making it look different. That’s a level of insanity we hope we’ll never arrive at.


Abdul J. Roberts, Esq. – Associate, Frier Levitt, LLC

As an Associate in Frier Levitt’s Healthcare Department, Abdul’s practice focuses on civil healthcare fraud litigation matters, government investigations, payor audits and overpayment demands, OIG exclusions and CMS revocation of billing privileges. Prior to joining Frier Levitt, Abdul was a criminal defense counsel in the United States Army Judge Advocate General (JAG) Corps handling trials for felony level Federal Criminal Offenses and appealing agency decisions on behalf of Soldiers. Abdul also served as a Trial counsel where he prosecuted Federal Criminal Offenses, and an administrative law attorney, where he advised senior level Commanders and agency heads on matters such as Freedom of Information Act (FOIA), Whistle Blower Protections, administrative investigations, and environmental law related issues.

Jim Tudor, PCA, CPC – Director, Coding & Billing Compliance, HealthCare Compliance Network, LLC

Jim is an expert in E&M auditing across all specialties, including professional and facility billing. He has designed and administered billing compliance and audit programs at the hospital level and for hundreds of provider physician organizations. He has extensive knowledge of federal regulations as they pertain to teaching settings and institutions, and in current billing guidelines for non-physician caregivers (“incident-to”). Jim has built coding database platforms for tracking, reporting, and productivity utilizing MS Access/Visual Basic. He has been a keynote speaker at several coding conferences and nationally broadcast webinars and has authored several articles for the AAPC Cutting Edge magazine.