1
Define the Question
Identify the code, service, claim element, or documentation issue being tested.
The Five-Step Audit Framework
Use the same sequence for coding accuracy reviews, documentation integrity checks, modifier validation, and targeted compliance audits.
2
Review the Record
Read the complete encounter and distinguish documented facts from inferred intent.
3
Validate Support
Compare the record with official coding guidance, payer rules, edits, and policy requirements.
4
Assess Impact
Determine whether the issue creates compliance, reimbursement, quality, or operational risk.
5
Document the Finding
State the condition, criteria, cause, impact, and corrective action without overstating intent.
Common Risk Signals
Risk signals are prompts for review - not automatic proof of an error.
Documentation Risk
- Conflicting or copied-forward statements
- Missing linkage, specificity, or clinical support
- Time-based services without qualifying time
Coding Risk
- Code selection exceeds documented intensity
- Modifier use changes payment without clear support
- Diagnosis sequencing does not reflect the encounter
Pattern Risk
- High-level services reported at unusual frequency
- Repeated overrides or edit bypasses
- Same issue across a provider, location, or service line
Write a Reproducible Finding
- ConditionWhat was documented, coded, billed, or omitted?
- CriteriaWhat authoritative rule or policy applies?
- CauseWhat process or knowledge gap likely contributed?
- ImpactWhat is the compliance, financial, or operational effect?
- RecommendationWhat correction, education, or monitoring is appropriate?
Keep Findings Defensible
Use objective language. Describe what the record supports and what it does not support.
Cite the applicable authority. Identify the guideline, edit, payer policy, or internal standard used.
Avoid conclusions about intent. A coding variance is not automatically fraud or abuse.
Preserve the audit trail. Retain the reviewed record, methodology, sample logic, and final disposition.
Three Questions Before You Finalize
Question 1Can another reviewer reach the same conclusion from the same record?
Question 2Did I cite the rule that supports the finding?
Question 3Did I separate the coding issue from assumptions about intent?
Think Like an Auditor. Code With Defensibility.
If it is not documented, it is not supported.