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How a Structured Audit Improved Coding Accuracy and Compliance

How a Structured Audit Improved Coding Accuracy and Compliance

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Challenge

A university vascular surgery department had growing concerns about potential revenue leakage. They were seeing inconsistencies in the documentation supporting billed services and suspected that some of their more complex surgical procedures were being undercoded. Without a systematic chart review process in place, it was difficult for them to validate coding accuracy or identify errors before claims went out the door. These gaps not only increased compliance risk but also suggested the department was missing revenue it had legitimately earned.

Our Approach

FD brought in our team of Certified Professional Coders (CPCs) to complete a structured, end-to-end audit focused on both coding accuracy and documentation quality.

Chart Selection & Review

We audited 20 surgical cases per provider across multiple providers and compared the operative notes against CPT/ICD coding and payer-specific guidelines. This allowed us to assess coding accuracy and identify patterns across the team.

Documentation Analysis

Our coders evaluated medical necessity, modifier usage and the level of detail included in the operative notes. During this review, we identified several instances where the documented complexity did not align with the codes billed.

Compliance & Education

We ensured every case was evaluated against CMS and payer rules to help the department strengthen compliance. From there, we prepared targeted education for both surgical and billing staff, focusing on the areas where clarifications or additional detail would have the greatest impact.

Reporting & Recommendations

We delivered a detailed audit report outlining:

  • Missed opportunities to bill at higher, accurately supported levels of service
  • Documentation gaps that could trigger compliance concerns
  • Clear recommendations to improve coding workflows and enhance communication between surgeons and billing teams

The Outcome

The audit confirmed what the department had suspected: 40% of the chart-reviewed cases supported a higher level of service than the codes originally billed. We also saw common documentation issues, including missing operative details in more complex procedures and incorrect modifier application when multiple surgeries were performed. These issues were directly tied to both lost revenue and heightened audit risk.

With a clearer picture of their coding patterns, the department was able to take immediate steps to improve accuracy and protect revenue. By identifying higher-supported services that had not been billed correctly, they uncovered opportunities for significant reimbursement increases.

Beyond the financial and compliance impact, FD’s engagement helped the department establish a more proactive operational foundation. We worked with their team to implement ongoing review protocols and develop education practices that support long-term accuracy.

Ready to protect your revenue and strengthen coding compliance?

Frazier & Deeter can help your organization optimize documentation, improve coding accuracy and reduce audit risk. Contact us today.

Contributors

Sarah Clarke, Partner, Frazier & Deeter Advisory, LLC

Heather Gibson, Senior Consultant, Frazier & Deeter Advisory, LLC

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