COMPLIANCE AUDITS: Top 5 mistakes all providers should avoid

By Bradley Reiner

I’ve been providing coding and documentation audits for over 10 years. I’ve audited thousands of records over that time. Over the last three to five years payer compliance audits have increased at an alarming rate and the issues have escalated. Consequently, refunds and penalties have increased as a result.

I would like to share some of my experiences in completing medical record audits. I will provide some ideas to increase your documentation and coding compliance and hopefully help you avoid future refunds and penalties.

Here are the top five mistakes I have identified that many providers are making when it comes to documentation:

#1 Chief complaint not documented appropriately
I know this may sound simple and you may be telling yourself that a chief complaint is always documented, but many of the records I review don’t have a clear and compliant chief complaint. Many physicians are documenting “Follow up” as a chief complaint. Contrary to popular belief this is NOT an appropriate chief complaint. If you further describe what the follow-up is for, such as “Follow up diabetes,” then it is a compliant chief complaint. Many auditors place a high level of importance on the documented chief complaint. This element is the first thing reviewed in the record for each visit and sets the tone for what is needed in the history, exam, and medical decision making. It literally gives the reader the information regarding the nature of the presenting problem and determines how the rest of the visit will progress. Don’t forget the importance of documenting a clear and appropriate chief complaint that includes the reason the member is being seen.

#2 Cloning of medical record documentation
Cutting and pasting language from one visit to another or one record to another is considered cloning of the documentation. This copying of documentation is happening more and more because of the addition of electronic medical records. These systems allow providers to cut things from a previous review of systems, history of the present illness, or examination and paste it on the current record, regardless of whether the visit required this information or these items to be provided. For example, I was reading a record recently that in the history of present illness the patient complained of headaches. In fact, the main reason for the visit was to discuss recurrent headaches. However, in the review of systems the patient denied headaches. This probably happened because a portion of the review was copied from a previous visit. This cloning of information in the medical record is becoming very concerning from an auditing standpoint. Insurance payers are very aware of information that is cut and pasted into other records. Ensure you only document what is truly appropriate for the nature of the problem that day. Don’t cut and paste from a previous visit if it has no relevance to the problem. More importantly, read the record before you finalize it to ensure it reads appropriately and consistently for each visit. This careful documentation will help ensure compliance.

#3 Level 3 new patient vs. level 3 established patient
There is a misconception that the documentation required for a level 3 established patient visit is the same as what is required for a level 3 new patient visit. This is incorrect. The documentation requirements for a new patient level 3 visit are defined as a detailed history and a detailed examination. For an established patient level 3 visit an expanded problem focused history and expanded problem focused exam are required. The area where most providers lack the appropriate documentation involves the history of the present illness. For level 3 new patients, it requires an extended history of present illness, which is four or more of location, quality, severity, duration, timing, context, modifying factors, and signs and symptoms. The status of three chronic conditions will also meet this level. For level 3 established patients, it only requires a brief HPI which is only one to three elements. This may not sound like much of a difference, but ensuring you meet the requirements is critical to maintain compliance. You must ensure you meet the level of the code billed. Level 3 new patients require 12-17 bullets as defined by the 1997 Documentation Guidelines for multi-system exams. It only requires 6-11 bullets for level 3 established codes. Again, this may not sound like much but it is significant and has a direct bearing on meeting a particular level. Make sure you understand the guidelines and the elements needed for the level being billed.

#4 Medical decision making
This area of documentation is where the rubber meets the road. This is the portion that ultimately drives the code choice. However, in many records I review this area is weak and not consistent with the code chosen. More documentation, if not warranted, does not increase the level of code that can be chosen if it is not necessary. Some of this is the fault of EMRs that have a system that chooses the code automatically. This problem can be significant and I have seen many examples where the code recommended is much higher than the medical decision making that has been documented. For example, an established patient may come in for a minor problem. The provider may document a comprehensive history and examination but these were not necessary based on the nature of the presenting problem. The EMR will most likely recommend the highest level code because of the amount of information documented in the history and examination. The system does not have the ability to determine if the documentation was actually appropriate for the presenting problem. It just counts the number of elements and makes a recommendation. Because this is an established patient, only two of the three elements (history, exam, and medical decision making) have to be met. The system will recommend the highest level based on this information, but the medical decision making, which drives code choice, is straightforward to low based on the nature of the problem. The service would need to be coded at a lower level based on the medical decision making. Ensure that you use medical decision making information choosing the most appropriate code for that visit.

#5 Documentation when time is a factor
As you may know, time is a controlling factor in code choice when over 50 percent of the visit is spent counseling or coordinating care. For example, if you see a patient for depression and spend the majority of your time counseling, then the service can be billed based on time rather than history, exam, or medical decision making. I’ve seen instances where the provider wanted to bill time, but only had the total time documented. This doesn’t meet the requirements for billing time. Here is the correct way to bill time. A patient came in, you spent 40 minutes with them, and over 50 percent was spent counseling. In order to bill time correctly, the record must indicate that a total of 40 minutes was spent with the patient over 50 percent of which was spent counseling. List all areas of the patient counseling to substantiate what was provided. Since each CPT code has a typical time associated with it, choose the code that represents the total time spent. In this instance, CPT 99215 would be chosen for an established patient. Keep in mind that time is not used regularly and should be considered an exception to standard documentation.

Following each of these tips will help you manage your medical records documentation and choose codes appropriately. These suggestions will also help decrease the possibility of a compliance audit and avoid refunds or penalties.


Bradley Reiner, formerly with Texas Medical Association, is now owner of Reiner Consulting and Associates. He can be reached at (512) 858-1570 or