Strong documentation is only half the battle when it comes to getting your practice paid correctly. Your codes must accurately reflect what the provider documented and the services your practice actually performed.

Get the coding wrong in either direction, and your practice can pay for it. Upcoding can trigger payer scrutiny, audits, repayment demands and potentially False Claims Act exposure. Downcoding can quietly drain revenue by causing your practice to receive less reimbursement than the services provided support.

That means coding accuracy isn’t simply your biller’s responsibility. It’s an important part of protecting your practice’s revenue and compliance.

Here are six ways you can tighten your coding and billing processes, catch problems earlier and improve the accuracy of the claims leaving your practice.

1. Audit Your E/M Coding Patterns Before a Payer Does

When was the last time you looked at the distribution of Evaluation and Management (E/M) codes by provider?

Pull reports showing the E/M levels billed by each provider and look for significant differences or unusual patterns. For example, if one physician consistently reports a much higher percentage of high-level E/M services than other physicians treating similar patients, investigate why.

An unusual pattern doesn’t automatically mean the coding is wrong. Differences in specialty, patient complexity, provider roles and patient populations can produce legitimate variations. But significant outliers give you a place to start your internal review.

Compare the claims to the underlying documentation and determine whether the code selected is supported. Don’t focus exclusively on potential overcoding, either. A provider who consistently selects lower E/M levels may be leaving legitimate reimbursement on the table.

Regular internal monitoring and auditing is also consistent with HHS Office of Inspector General (OIG) compliance guidance for physician practices. OIG identifies internal monitoring and auditing, appropriate training and education, and corrective action among the components of an effective physician compliance program.

Action Step: Review E/M utilization by provider regularly and investigate significant outliers in either direction.

2. Tighten Your Modifier 25 Process

Modifier 25 deserves special attention because it can affect both reimbursement and compliance.

CMS states that Modifier 25 may be appended to an E/M code when another procedure or service is reported on the same day and the E/M service is significant and separately identifiable.

The problem occurs when a modifier is added simply because your practice wants to receive separate payment for an E/M service performed on the same day as another procedure. Your documentation has to support it.

Before submitting a claim with Modifier 25, make sure your team can identify exactly what made the E/M service significant and separately identifiable from the other service performed. This is an area worth monitoring. In February 2026, CMS highlighted an OIG finding involving improper billing of E/M services with Modifier 25 on the same day as intravitreal injections.

Don’t wait until a payer asks for the documentation to find out your process isn’t working.

Action Step: Periodically audit claims containing Modifier 25 and compare the code directly to the provider’s documentation.

3. Catch Coding Errors Before You Submit the Claim

Once an inaccurate coding practice becomes routine, you may end up repeating the same mistake across dozens—or even hundreds—of claims. That’s why a relatively small pre-claim review can be valuable.

Create a checkpoint between coding and claim submission for higher-risk claims. You don’t necessarily need to review every claim. Instead, concentrate your resources where mistakes are most likely or most costly. Consider reviewing claims involving:

• New providers
• New coders or billing staff
• Frequently denied services
• Higher-level E/M codes
• Frequently scrutinized modifiers
• Newly introduced CPT or ICD-10-CM codes
• Services affected by recent payer policy changes
• Codes that have previously created audit or denial problems

You can also spot-check a small number of claims for each provider regularly. When you identify a problem, expand the sample to determine whether you’re looking at an isolated mistake or a larger pattern.

The goal isn’t simply to catch individual errors. It’s to find the process, documentation or training problem causing them.

Action Step: Create a short list of high-risk claims that require additional review before submission.

4. Don’t Hand Off Compliance When You Outsource Billing

Outsourcing your billing can reduce your team’s workload, but it doesn’t mean your practice should stop monitoring what is being submitted in its name. Ask your billing company for meaningful reports instead of assuming everything is being handled correctly.

At a minimum, you should be able to monitor information such as denial rates, corrected claims, coding changes, aging accounts and recurring billing problems. Also establish clear rules regarding who has the authority to change a code.

For example, what happens when your billing company believes the documentation doesn’t support the code your provider selected? Does the biller change it? Does the claim go back to the provider? Who documents the reason for the change?

These questions should be answered before a problem occurs. Third parties can create compliance exposure, too. The Department of Justice has specifically discussed situations in which coding consultants and billing specialists may contribute to improperly inflated Medicare claims. Your practice needs visibility into what’s being submitted on its behalf.

Action Step: Establish written expectations for your billing vendor and regularly review reports for coding changes, denials and recurring problems.

5. Protect Revenue From Timely Filing Losses

You can have perfect documentation, the correct diagnosis, the right CPT code and a clean claim—and still receive nothing if you miss the payer’s timely filing deadline. For Medicare fee-for-service claims, the general timely filing period is 12 months, or one calendar year, after the date services were furnished. Commercial payer deadlines can be significantly shorter and vary by contract.

Don’t rely on your billing team’s memory to keep these requirements straight. Build a payer-specific timely filing reference that includes:

• Initial claim filing deadline
• Corrected claim deadline
• Reconsideration requirements
• Appeal deadline
• Required documentation
• Payer-specific submission instructions

Review these requirements when you enter into a new payer contract and whenever a payer updates its policies.

You should also have an aging process that flags unsubmitted claims well before the deadline approaches. Waiting until a claim is 85 days old to discover a payer has a 90-day filing requirement doesn’t give your team much room to fix the problem.

Action Step: Create a payer-specific filing calendar and set internal deadlines well ahead of each payer’s actual cutoff.

6. Stop Treating Denials as Individual Problems

When a claim is denied, the immediate goal is usually obvious: fix it and get it paid.

But stopping there can cost you. A denial may be telling you that something earlier in your revenue cycle is broken. If you repeatedly receive denials involving the same code, modifier, provider or payer, don’t simply continue correcting and resubmitting claims. Find the underlying cause. Track denial reasons in categories such as:

• Coding error
• Missing or insufficient documentation
• Medical necessity
• Modifier issue
• Eligibility
• Authorization
• Timely filing
• Payer-specific coding policy
• Provider documentation
• Billing system or claim-edit problem

Then review your denial trends regularly.

For example, if Modifier 25 denials suddenly increase, determine whether the problem involves provider documentation, coder training or a payer policy change. If one provider’s E/M claims are frequently downcoded or denied, review the documentation and coding patterns rather than addressing each claim separately.

Every recurring denial you prevent saves your team from having to work the same problem again.

Action Step: Track the root cause of denials—not just the payer’s denial code—and use the results to determine where additional training or process changes are needed.

Coding Accuracy Is Both a Revenue and Compliance Strategy

One of the biggest mistakes a practice can make is viewing coding compliance and revenue optimization as competing goals. Accurate coding accomplishes both.

Your goal isn’t to code higher or lower. It’s to capture every dollar your documentation legitimately supports while avoiding reimbursement your documentation doesn’t support. That distinction matters.

The Department of Justice continues to pursue healthcare False Claims Act cases involving allegedly inaccurate coding. For example, in 2025 a dermatology practice and surgery center agreed to pay nearly $850,000 to resolve allegations involving falsely coded wound-repair claims. The government alleged that inaccurate codes resulted in Medicare paying more than it should have.

At the same time, excessive caution can create its own financial problem. Habitual downcoding means your practice may perform medically necessary, properly documented services without collecting the full reimbursement you’ve earned.

The answer is a repeatable process: accurate documentation, educated coders, internal auditing, payer monitoring and fast corrective action when you identify a pattern.

Keep Your Entire Team Up to Date With the Annual All-Access Pass Coding rules, payer requirements and compliance risks don’t stand still—and neither can your team. With Healthcare Training Leader’s Annual All-Access Pass, your entire practice gets ongoing access to expert-led training covering medical billing, coding, reimbursement, compliance, credentialing and practice management. Instead of purchasing training every time a new rule or problem arises, you can give your team the tools to respond quickly, strengthen accuracy and protect your practice’s revenue throughout the year. Give your entire team the training they need to get claims right the first time, reduce costly mistakes and stay ahead of changing requirements.

 

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