How to Audit Your Billing Patterns?
Quick Answer
To audit your billing patterns, follow this five-step process: (1) Pull your E&M code distribution for the past 12 months from your billing system or use NPIxray's free NPI scan, (2) Compare your 99213/99214/99215 percentages to specialty benchmarks, (3) Select 20 random charts and re-evaluate the E&M level using MDM criteria, (4) Check for care management billing gaps (CCM, RPM, BHI codes = zero claims?), and (5) Calculate your AWV completion rate versus your total Medicare panel. NPIxray automates steps 1, 2, and 4 by analyzing your actual CMS Medicare billing data against 1.175M provider benchmarks. A thorough self-audit takes 2-4 hours and typically reveals $15,000-$60,000 per provider per year in addressable revenue gaps. Most practices should conduct a billing audit quarterly. Source: NPIxray analysis of 1.175M Medicare providers and 8.15M billing records.
Step 1: Gather Your Billing Data
Start by pulling your E&M code distribution for the past 12 months. You need: the total count of each E&M code billed (99211-99215 for established patients, 99202-99205 for new patients), total Medicare charges and payments by code, number of unique Medicare beneficiaries seen, and any care management codes billed (99490, 99439, 99491, 99454, 99457, 99458, 99484, G0438, G0439).
Your billing system or practice management software should be able to generate this report. Alternatively, NPIxray provides this data for free by analyzing your CMS Medicare billing records — just enter your NPI number. The advantage of NPIxray is that it also provides the benchmark comparisons automatically.
Step 2: Compare to Specialty Benchmarks
Calculate the percentage of established patient visits at each E&M level and compare to your specialty benchmark. For Internal Medicine, the expected distribution is approximately: 99212 (2-4%), 99213 (25-30%), 99214 (42-48%), 99215 (8-12%), with the remainder being 99211 and other codes.
Key red flags include: 99213 percentage more than 10 points above benchmark (likely undercoding), 99214 percentage more than 10 points below benchmark (likely undercoding), 99215 at less than 5% (likely missing high-complexity visits), and no 99205 (new patient high complexity) codes at all. Any of these patterns indicate a coding optimization opportunity.
Step 3: Chart-Level Audit
Select 20 random charts from the past month. For each chart, independently evaluate the E&M level using the MDM table: count the problems addressed (not just the chief complaint), identify all data reviewed (labs, imaging, external records, discussions with other providers), and assess the risk level (prescription management, surgery decisions, hospitalization risk).
Apply the 2-of-3 rule to determine the supported code level. Compare your independently assessed level to what was actually billed. If more than 15-20% of the charts support a higher code than what was billed, you have a systematic undercoding issue. Document your findings and calculate the per-visit dollar impact.
Step 4: Care Management Gap Analysis
Check whether you are billing any care management codes. If the following codes appear zero times in your billing data, you have untapped revenue: 99490/99439/99491 (CCM) — you likely have 150+ eligible patients generating zero revenue. 99454/99457/99458 (RPM) — patients with monitorable chronic conditions are not being remotely monitored. 99484 (BHI) — 20-30% of your Medicare patients likely have treatable behavioral health conditions. G0438/G0439 (AWV) — compare the count to your total Medicare panel. If fewer than 50% had an AWV, there is significant room for improvement.
For each gap, estimate the revenue impact: number of eligible patients multiplied by monthly reimbursement multiplied by 12 months. This gives you the total annual revenue opportunity for each program.
Step 5: Create an Action Plan
Rank the identified gaps by revenue impact and implementation difficulty. Typically, E&M coding optimization is the quickest win (high impact, low difficulty), followed by AWV completion improvement, then CCM program launch, RPM, and BHI.
For each gap, set a specific, measurable goal: increase 99214 billing from 32% to 44% within 6 months, enroll 50 patients in CCM within 4 months, increase AWV completion from 48% to 65% within 12 months. Assign a responsible team member for each goal and schedule monthly progress reviews. Re-run the full audit quarterly to track improvement and identify new opportunities.
Frequently Asked Questions
How many charts should I audit?
A minimum of 20 charts provides a statistically meaningful sample for identifying coding patterns. For larger practices, audit 10 charts per provider. Focus on established patient visits (99213-99215), as these represent the bulk of E&M billing and the most common undercoding patterns.
Should I hire an external auditor?
External coding auditors provide an unbiased assessment and detailed education on documentation gaps. Typical costs are $2,000-$5,000 for a comprehensive audit. The ROI is usually positive within 1-2 months of implementing their recommendations. For a starting point, NPIxray's free NPI scan identifies the gap without cost.
How often should I audit?
Conduct a full billing audit quarterly. Monthly spot-checks (5-10 charts) can help you track progress between quarterly reviews. If you are launching a new program (CCM, RPM), audit the new codes specifically after the first 30-60 days to ensure billing accuracy and compliance.
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