Do you hope for the perfect audit review meeting? You audit an entire team of providers who either have 100% accuracy or they don’t, but they greet your feedback with grace and humility. It helps when you of direct communication and real curiosity and engagement with the medical team, but results are not guaranteed.

Auditing professional fee encounters was part of my daily work for many, many years. For some practitioners, I was hired to do one review only. For some practices, I audited their office and hospital services every year for a decade or more. Typically, these were reviews of ten encounters that the clinician had coded, although in other types of audits I was auditing the coder. The audit included Evaluation and Management (E/M) services, minor procedures, modifiers, and diagnosis coding. Some audits included critical care, a preventive and problem visit on the same date of service, incident to services or shared services. These were audits chiefly for compliance but were also used to identify missed revenue opportunities.

Start With a Question

I always started the meeting with one question. “Before I get to my agenda, are there any coding questions that you want to discuss at this meeting?” I wanted the practitioner to know that it was their meeting and not my meeting. I thought that set the tone for the meeting by putting them in the driver seat.

Was that successful? Mostly it was. Sometimes, I would lose control of the meeting because the practitioner had many things that they wanted to discuss or opinions about coding and reimbursement in general. Sometimes, and I think this was even harder situation, the practitioner would say no I have no questions and then respond to each of my statements briefly. “Yes.” “No.” “Yes,” so that our half hour meeting was done very quickly. If the clinician really didn’t want to engage, I found that more difficult than a practitioner who had a lot to say.

A colleague of mine who regularly performs audits was confounded that I’d invite a question first: generally, she said it would result either in their questioning her qualifications or immediately discussing data points. (Data points, everyone’s favorite….) However, putting the provider at ease is always the primary rule, so she explains that she is auditing to make sure that they are paid for the work they perform and to make sure their documentation reflects the work – not to be punitive.

Deliver the News

When I had general agreement with a practitioner, I would always start with good news and show the report immediately. The audits had a column for comments and when there was general agreement, these comments would drive the conversation. Perhaps there was a diagnosis code that was unspecified and based on the documentation a more specific diagnosis code could not be selected. In that case, we would discuss the structure of the code category and what would need to be documented in order to find a more specific code. Sometimes, there would be an opportunity for either a higher level of service or an additional service that could have been reported.

Naturally, it is more difficult when I wasn’t in general agreement with the codes selected. After asking the question about their questions, I didn’t immediately show the report. I would discuss the findings. Perhaps it was a discussion about modifier 25 and an office visit reported when I audited only a procedure. I might start with an educational discussion about CPT and Medicare rules for reporting both services. I might give examples of when both could be reported and when only one could be reported. If there were issues with level of service, I might start by discussing typical scenarios for that specialty (specialty specific examples are key) when a level two or three or four or five could be billed. I wanted to establish a collegial relationship and discussion prior to the bad news. After we had talked about the concepts, then I would show the report.

My colleague said she likes to get the report over with. She’s afraid that any delay on reporting the outcome will cause the recipient to be distracted. She explains why she came to her conclusion and then states “but I can be persuaded otherwise” to kickstart the conversation. Usually, by the end of the discussion, she either has more source material to back-up her findings or the providers are glad to have learned something new and move forward.

Anticipate Problems

Working with the same clinicians year after year gave me the opportunity to anticipate problems. Most of these groups were individual meetings, but sometimes I would meet with a small group of a few practitioners of the same specialty at a meeting. I’ll never forget one of those meetings. It was a surgical specialty and they were incorrectly using a current malignant neoplasm diagnosis when according to ICD -10-CM rules, it should have been a personal history of malignant neoplasm. I believe they were getting paid for those office visits but they were very angry. The next year, I asked the practice manager to join me in the follow up meeting with that group. That could also occur with an individual practitioner, too. Whatever the issue was, whether the services reported really met the criteria of critical care or if a separate office visit should have been billed with that preventive service, when my past experience with a clinician was less than optimal, I would ask the practice manager to join in the meeting.

My colleague, weighing in again, explained to me that as having been part of a compliance office that often-delivered bad news, it was expected that she and her colleagues work in pairs. Not only did the pair check each other’s facts/outcomes for a given result, if a discussion got heated and barbs directed at one of the pair, the other could deflect any overly emotional volleys and also act as a civility check: not too many people want to be caught out behaving poorly in front of a witness. This seems like a great policy and practice to me.

Internal Coding Expert

In some of these groups I met with practitioners by myself. In some groups the internal coding expert for that practice joined me. When that was the case, it was critically important that the internal coding expert and I were on the same page when we met with the practitioner. That doesn’t mean we had to be clones in all of our opinions. But, we had to be in basic agreement about the audit results and the citations for the support of the results. Of course, there were times when we might be one level difference from one another but it was important to address that prior to a meeting with a practitioner. And, there are many times when after discussion with the internal coding expert, I changed my report.

My valued colleague, ever the commenter, agreed that finding a common ground with an internal coder prior to meeting with a provider, or even an office manager, could help that internal coder save face or vice versa. We know that it’s hard to remember everything and even keep up with local state policy updates. She said that the one level difference could either be explained or turn into a forehead slapping moment of “oh brother – how did I come up with that level?” Using the coding guidelines are a great way to establish camaraderie with other coders and build trust.

What’s the central theme to all of this? Open communication and dialogue with the billing and coding team: from the provider to the coder and office administrator. We’re all seeking to assist providers and staff to attain that 95% correct coding percentage and knowing the why of how something occurred is the only way to get to compliant outcome.

Betsy Nicoletti, 3/10/2026