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Medical Practice
Billing Audit Checklist

34 audit items across 7 sections. Find the billing gaps costing your practice revenue and the compliance gaps putting it at risk.

34 items across 7 sections

Claim Submission Accuracy

Correct NPI type used per payer requirement (Type 1 individual vs. Type 2 organizational)
Required modifiers attached where applicable (bilateral, multiple procedures, assistant surgeon)
ICD-10 codes at highest level of specificity (no unspecified codes where specific codes exist)
CPT/HCPCS codes validated against current payer fee schedule for the date of service
Diagnosis-to-procedure linking documented; medical necessity supported for every line item

Documentation Completeness

E/M level supported by medical decision-making complexity or total time documented
Procedure notes include all elements required by payer policy
Prior authorization on file for every service that requires it, attached to the claim
Referring and ordering provider information complete on specialist and ancillary claims
Supervising physician co-signature present on mid-level provider (PA/NP) claims where required

Denial Pattern Analysis

90-day denial report pulled and sorted by denial reason code
Top 5 denial codes identified by dollar volume, not just volume
Denials categorized: clinical (medical necessity), administrative (missing info), or duplicate
First-pass clean-claim rate calculated (benchmark: ≥ 95%)
Payers with denial rates exceeding 10% flagged for contract and submission review

Accounts Receivable Health

Days in A/R calculated for the last 90 days (benchmark: < 45 days for most specialties)
A/R aging analysis run: percentage of balance over 90 days should be < 10%
Claims older than 120 days without resolution identified and actioned
Timely filing deadlines reviewed by payer for all open claims approaching cutoff
Credit balance accounts reviewed; patient refunds issued as required by law

Coding Accuracy & Undercoding

Random sample audit: 20 charts pulled, coded independently, then compared to what was billed
Systematic undercoding identified (e.g., Level 3 billed when Level 4 is supported by documentation)
High-frequency CPT codes reviewed for correct modifier usage and sequencing
Split/shared billing rules applied correctly for physician–PA/NP teams
Global period rules verified on all post-operative claims (no unbundled services in the global window)

Payer Contract Compliance

Fee schedules loaded in the practice management system match current signed contracts
Non-covered services identified and removed from the standard billing workflow
Bundling edits reviewed (no inappropriate unbundling of services the payer considers inclusive)
Coordination of benefits rules applied correctly for dual-⁠coverage patients

PHI Security & Compliance

PHI transmissions use encrypted channels (TLS 1.2 or higher) for all payer and clearinghouse connections
Business Associate Agreements (BAAs) on file for every vendor with access to patient billing data
User access to billing systems reviewed; principle of least privilege applied
EHR and billing system access logs audited for anomalous access patterns
Data retention policy meets HIPAA minimum (6 years from creation or last effective date)

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Medical Practice Billing Audit Checklist