How routine coding audits can protect your practice
By Featured article
Accurate medical coding is essential for protecting your practice against external audits, maintaining compliance, and delivering proper reimbursement. The Centers for Medicare and Medicaid Services (CMS) implemented changes this year aimed at streamlining the coding structure for Evaluation and Management (E/M) services. Previously, the focus was on the time spent with patients; however, the new CMS guidelines emphasize medical decision-making (MDM).
The key areas of focus in Medical Decision Making are:
- The number and complexity of a patient’s issues
- The amount and complexity of data reviewed
- The risk associated with the patient’s health management
The new emphasis is on whether the patient’s condition directly influences the clinical decision-making process, rather than on the duration or thoroughness of history taking and physical examinations. While comprehensive exams may still be conducted for complex cases, they're no longer mandatory for certain coding levels.
It's best not to rely solely on your Electronic Health Record (EHR) for coding, as it might not capture all services rendered. Proper documentation and coding are essential for ensuring appropriate reimbursement. For in-depth information, see the AMA and CMS E/M 2025 coding guidelines. In addition, consider using HCPCS codes G2211 and G2212 to account for the complexity of office visits and prolonged services (15+ minutes). CMS provides downloadable resources for further guidance.
How InfoDive can help you with these changes
Our robust analytics platform InfoDive is designed to help your practice navigate changes like these, optimize your coding practices, and uncover revenue opportunities. By examining current and historical data, InfoDive provides insights into the financial impacts of coding changes, helping you to adjust your strategies accordingly.
Five ways you can use InfoDive to support your practice
- Analyze the financial impact of coding changes
Understand how updates to fee schedules or guidelines may affect your revenue, and identify areas where enhanced documentation or coding can make a significant difference.
- Benchmark your practice’s performance
Compare your coding trends with industry standards and peers within your specialty to pinpoint areas for improvement and ensure consistency across providers.
- Identify provider-level coding trends
Review individual provider patterns to uncover instances of under-coding or over-coding, allowing for timely corrective actions.
- Conduct targeted chart audits
Quickly generate a list of patients, billing codes, and diagnosis codes for reviewing potential lost revenue.
- Optimize coding for complex care cases
Identify patient visits where G2211 or G2212 was billed, to better understand other instances where it may not have been used but could have been applicable.
As you can see, InfoDive provides actionable insights into how coding affects your practice, and highlights opportunities for improving accuracy and compliance. With these tools, your practice can prevent revenue loss, stay compliant with current regulations, and make well-informed decisions. To learn more about how InfoDive can support your practice, please speak with your Cencora account manager or contact us at ProviderClientServices@intrinsiq.com.
