decisionhealth Newsletters, Part B News - 2014 Issue 6 (June)
Conduct annual chart reviews to reduce downcoding, maintain compliance
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Article Overview
This article explains why routine chart reviews matter for evaluation and management coding and how practices can use audits, utilization trend review, and coding resources to identify underbilling patterns. It is aimed at coders, practice managers, and clinicians who want a broader understanding of chart review processes, documentation awareness, and compliance-focused billing oversight.
Why This Topic Matters
Underbilling can reduce revenue and mask documentation or coding issues that affect compliance. The article helps readers understand the operational value of annual audits and practice-level monitoring for E/M billing accuracy.
Article Sections
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Care documentation
Introduces the article’s focus on documentation and coding review in the context of evaluation and management services.
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4 tips to reduce underbilling
Outlines practical practice-management topics related to chart review frequency, coding education resources, billing trend monitoring, and EHR tool use.
What You Will Learn
- Why routine chart review is used in evaluation and management coding oversight
- How practices can think about documentation review as part of revenue and compliance monitoring
- What broad categories of resources and tools may be used to support coding education and trend analysis
- Why billing pattern review can be important for identifying potential underbilling
Who Should Read This
- Medical coders
- Practice managers
- Physicians and other clinicians
- Billing and compliance staff
- Coding educators and consultants
Codes Discussed
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