In today’s rapidly changing healthcare landscape, inaccurate billing and coding can lead to lost revenue, denied claims, compliance violations, and even audits. For large specialty practices, routine billing and coding audits are no longer optional – they are essential.

TriumpHealth empowers medical practices to protect their revenue, improve workflows, and stay audit-ready with expert-driven, benchmark-aligned audit services.

Why Billing and Coding Audits Matter More Than Ever

An effective billing and coding audit does more than just ensure compliance – it’s a strategic tool to:

• Uncover hidden revenue opportunities
• Correct undercoding or overcoding issues
• Improve documentation quality and accuracy
• Prevent denials and reduce rework
• Boost clean claim rates and streamline your revenue cycle

Benchmark-driven audits can increase revenue by up to 20% by identifying missed charges and coding errors.

What to Include in a Comprehensive Billing & Coding Audit

At TriumpHealth, our audit methodology is built around industry-recognized KPIs and compliance best practices. Each audit area is designed to improve accuracy, efficiency, and revenue integrity.

1. Documentation and Coding Accuracy

Purpose

Ensure that billed services are supported by proper clinical documentation and that CPT, ICD-10, and HCPCS codes are applied accurately.

Audit Checklist

• Review of E/M services against CMS guidelines
• CPT/ ICD validation using coding guidelines and payer edits
• Specialty-specific procedures (e.g., excisions, skin grafts, injections)

Key Metric

Coding Accuracy Rate (see Key Performance Metrics and Benchmarks table below)

2. Modifier Usage

Purpose

Assess the correct application of common and specialty-specific modifiers that impact reimbursement, such as:

• Modifier 25 – Significant, separately identifiable E/M
• Modifier 59 / XS – Distinct procedural service
• Modifier 91 – Repeat clinical diagnostic lab test
• LT / RT – Laterality for anatomical procedures

Audit Focus

• Ensure modifiers are not misused to bypass bundling edits
• Validate medical necessity and documentation for each modifier
• Cross-check against payer-specific requirements (e.g., Anthem vs. Medicare)

Common Pitfalls

• Modifier 25 used without documentation of separate E/M
• LT/RT incorrectly applied for bilateral procedures
• Modifier 59 stacked with 51 or used when X(E/P/S/U) modifiers are required

3. Charge Capture and Billing Lag

Purpose

Ensure that all services rendered are captured, documented, and billed timely.

Key Metric

• Missed Charges Rate (see Key Performance Metrics and Benchmarks table below)
• Billing Lag Days (see Key Performance Metrics and Benchmarks table below)

4. Clean Claim Rate and Rejection Prevention

Purpose

Measure how many claims are submitted cleanly the first time, without requiring correction or resubmission.

Audit Activities

• Use claim scrubbers and payer-specific edits
• Validate field population (e.g., missing referring provider NPI)
• Check CPT/ICD crosswalks and NCCI edits

5. Denials and Appeals Analysis

Purpose

Identify trends in denials and evaluate how well your team responds with appeals.

Key Metric

• Initial Denial Rate (see Key Performance Metrics and Benchmarks table below)
• Appeal Success Rate (see Key Performance Metrics and Benchmarks table below)

Audit Steps

• Categorize denials (coding, auth, eligibility, etc.)
• Check if appeal documentation meets payer requirements
• Track timeliness of appeal submissions (ideally ≤ 14 days of denial)

Use denial reason codes (e.g., CO-50, CO-197, PR-204) to categorize and prioritize training needs or payer re-negotiations.

Key Performance Metrics and Benchmarks

KPI Category	Formula	Target Benchmark
KPI		Target
Coding Accuracy Rate	Correct Codes / Total Codes Reviewed	≥ 95%
Modifier Usage Accuracy	Correct Modifier Use / Total Modifier Instances	≥ 98%
Missed Charges Rate	Unbilled Encounters / Total Encounters	≤ 2%
Billing Lag (Days)	Submission Date – Service Date	≤ 2 days
Clean Claim Rate	Claims Accepted on First Submission / Total Claims Submitted	≥ 98%
Initial Denial Rate	Denied Claims / Total Claims Submitted	≤ 5%
Appeal Success Rate	Approved Appeals / Total Appeals Filed	≥ 75%

How Often Should You Audit?

• Quarterly: Full audits across departments
• Monthly: Spot-checks for high-risk specialties or new providers
• Annually: Full-scale audit for payer and OIG compliance

Who Should Be Involved in the Audit Process?

A successful audit requires collaboration. Key stakeholders include:

• Certified coders and billing team
• Office managers and administrators

Compliance officers or third-party audit experts (e.g., TriumpHealth)

From Insight to Action – Your Post-Audit Roadmap

A billing and coding audit isn’t just a compliance check – it’s an opportunity to transform how your practice operates. But the audit’s value lies in what happens after the findings are delivered.

Here’s how to turn insights into lasting results:

1. Deliver Targeted Training to Coders and Billers

Schedule one-on-one and group training sessions to review:

• Common coding errors (e.g., incorrect E/M levels, missed modifiers)
• Payer-specific documentation gaps
• Changes in CPT/ICD codes, modifier use, or billing protocols

2. Close Documentation Gaps with Providers

Share audit findings with providers in a constructive manner:

• Highlight under-documentation or over-documentation trends
• Discuss best practices for coding support (e.g., time-based billing, HCC capture)
• Create specialty-specific cheat sheets or EHR smart phrases

3. Update Internal Billing Templates and EHR Prompts

Based on audit feedback:

• Refine charge capture templates (e.g., missing procedural fields)
• Adjust EHR billing prompts for common code combinations
• Incorporate reminders for common modifiers (e.g., 25, 59)

4. Adjust Payer-Specific Workflows

If denials or rejections were concentrated with certain payers:

• Revisit and update the payer-specific billing rules
• Implement pre-check logic for claims going to those payers
• Train teams on insurer nuances (e.g., BCBS vs. Medicare modifier use)

5. Track Improvement Through KPI Dashboards

Use audit benchmarks to set performance goals:

• Clean Claim Rate ≥ 98%
• Denial Rate ≤ 5%
• Billing Lag ≤ 48 hours
• Appeal Success ≥ 75%

Build a dashboard that tracks these KPIs monthly to measure post-audit improvement.

6. Re-Audit High-Risk Areas Within 90 Days

Don’t wait until the next annual audit to check progress. Re-assess:

• Denial-prone CPT codes
• Providers with multiple documentation issues
• Modifiers with frequent misuse

7. Formalize Changes Into SOPs and Training Protocols

Document all changes made as a result of the audit, and incorporate them into:

• Standard Operating Procedures (SOPs)
• Onboarding training for new billing staff
• Quarterly compliance updates

By executing these post-audit actions with structure and accountability, your practice will not only correct existing issues but also create a more resilient and revenue-optimized operation.

Best Practices for Sustained Audit Success

• Standardize expectations using TriumpHealth RCM KPI Policy Checklist
• Conduct quarterly training for coding, billing, and documentation staff
• Track audit KPIs via real-time dashboards
• Adopt a proactive audit model – prevent errors before they cost you

Why TriumpHealth? A Trusted Audit Partner for Medical Practices

From dermatology to cardiology to plastic surgery and ASCs, TriumpHealth brings deep specialty insight and a track record of results. Our certified revenue cycle management professionals provide:

• Detailed audit reports
• Remediation and coding education
• Denial prevention strategies
• Custom KPI dashboards and tracking

Stay Compliant – Boost Revenue – Reduce Denials

Schedule A Consultation with TriumpHealth’s expert billing and coding audit team and take control of your revenue cycle today. Schedule a complimentary discovery call to learn how we can help you maximize revenue while staying compliant. For more details contact us at 888-747-3836 X0 or email us at [email protected]