Auditing and Educational Programs Improve Large Physician Group's Coding Accuracy


As a large physician group based in the Midwest added more physicians, group leaders realized there were no processes in place to audit coding on patient claims for compliance with guidelines from the Centers for Medicare & Medicaid Services (CMS).

Furthermore, the group did not provide education on clinical coding and documentation to physicians and other clinicians. Consequently, about 40% of patient claims were either undercoded or overcoded.


The physician group partnered with Guidehouse to provide its practices with annual claims compliance audits, special reviews of patient claims, and physician education on clinical documentation.

After reviewing provider CMS claims, Guidehouse trainers conducted educational sessions with physicians whose claims scored less than 90% accuracy. Subsequent audits focused on provider claims with coding outside CMS norms for error rates, as well as claims from providers new to the practice.

In addition, a policy was developed that requires all new providers to meet with trainers within their first 90 days of hire to ensure understanding of coding and documentation guidelines. Ongoing monitoring of evaluation and management documentation patterns was also instituted across practice sites to detect potential risks.

As the group transitioned to the Epic electronic health record system, Guidehouse also reviewed documentation templates created by physicians to ensure compliance with CMS guidelines.


As a result, the physician group’s providers have a better understanding of how to accurately document patient encounters, as well as select the appropriate level of service.

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