the importance of a coding review

The Importance of a Coding Review

You may recall our blog titledThe Advantages of Medical Coding Compliance from June 17, 2015, and we want to remind everyone that having an active compliance program is key to avoiding financial penalties, and possible exclusion from the Medicare program, for fraudulent billing and coding activities.  We recently read a blog by Cheryl Toth of Karen Zupko and Associates titled “OIG Says ‘No Bonus Points’ for Having a Compliance Plan”, that will open your eyes on the topic.  The article essentially states that just having a medical billing and coding compliance plan is not enough… you have to show that the plan has been implemented and your practice is taking active steps to achieve compliance and reduce fraudulent claims. 


A major component of your compliance program should be prevention.  Your medical practice should have an active audit program to review claims on a regular basis to ensure compliance.  Whether you perform internal audits, or use an external billing company, such as Concordis Practice Management, LLC, to conduct your audit and review your claims, having documentation of the coding review is imperative.  You may be able to perform the audits internally if your practice employs several coders; however, we recommend using an external billing company to review your claims if you have a small practice. 


The coding review should focus on all professional fee billing claims performed by physicians and non-physician providers, and there should be a reasonable sample size to include various types of claims submitted, such as regular office visits and procedures/surgeries performed.  Concordis Practice Management, LLC has Certified Professional Coders (CPC’s) on staff that will do a complete assessment of your coding and reimbursement practices. The CPC reviewer will verify that documentation in the medical records supports CPT, HCPCS, and ICD codes assigned. The objective of the review is to identify under-billed, over-billed, undocumented, denied, and down-coded services. We can also provide training for your providers to enhance proper medical records documentation.

Additionally, we would ensure your practice is complying with its medical billing and coding compliance plan.  The Centers for Medicare and Medicaid Services (CMS) has several references to assist a practice with developing a medical compliance plan if you do not have one.   Concordis Practice Management, LLC can assist with the development of the plan if you do not have the time or resources.


The Federal government estimates that 12.7% of all Medicare Fee for Service claim payments are improper.  This does not necessarily mean the claims were overpaid, but also includes those claims that have been underpaid.  CMS has an arsenal of Claim Review Programs to ensure physician practices are submitting claims properly.  There is an array of “alphabets” that you may have heard… ZPIC, SMRC, CERT, RAC, and the list goes on and on.  Here are some of the various types of programs to ensure your coding and billing practices are correct:

  • ZPIC – Zone Program Integrity Contractors:  Perform investigations that are unique and tailored to the specific circumstances and occur only in situations where there is potential fraud, and take corrective actions.
  • SMRC – Supplemental Medical Review Contractors:  Conduct nationwide medical reviews as directed by CMS for identifying overpayments and underpayments.
  • CERT – Comprehensive Error Rate Testing Contractors:  Collects documentation and perform reviews on statistically valid random sample of Medicare Fee for Service claims to produce an annual improper payment rate.
  • RAC – Medicare Fee for Service Recovery Auditors:  Review claims to identify potential underpayments and overpayments, as part of the Medicare Recovery Audit Program.

We should point out that some of the agencies perform prepayment audits, and other agencies perform post-payment audits.   Regardless of their mission, the agencies mentioned in this article intend to ensure your claims are properly submitted for the services provided.  It is also important to remember that if you receive correspondence from one of these agencies that you respond to the issues immediately.  The key to success and avoid problems is having an active compliance plan and conduct regular coding reviews.  Contact Concordis today for a professional consultation regarding a coding review. 


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