Besides protecting your practice from potentially disasterous outside audits, performing internal audits regularly can reveal missed revenue. In fact, undercoding is as common as overcoding. That’s because many physicians nervously enter a code reflecting a lower level of service than they actually provided.
Not only does such unwarranted fear cost you money, but a consistent pattern of undercoding attracts auditors’ attention just as much as the more infamous upcoding.
The primary determining factor in coding is the complexity. As a rule of thumb, ask yourself whether the patient would likely get well without medical intervention. Educating yourself and your staff so you code at the appropriate highest level can result in increased revenue.