Work with medical billers who understand your EHR's billing process
A chart-level review of your CPT, ICD-10, and modifier usage, benchmarked against CMS CERT data and AAPC accuracy standards. Built for multi-site groups and health systems with 15 or more providers.
CMS reported a 6.55% Medicare fee-for-service improper payment rate for FY2025, $28.83 billion, mostly tied to documentation gaps rather than fraud. At 40,000 claims a month, one percentage point of coding-driven error stops being a rounding line and becomes exposure most systems can't see until it's audited for them, especially against the 95% industry accuracy benchmark almost no one measures internally.
The FY2025 Medicare fee-for-service improper payment rate, down from 7.66% in FY2024. CMS attributes most of the gap to insufficient documentation rather than fraud.
OIG and CMS guidance calls for every physician and non-physician provider to have their coding reviewed at least once a year, with frequency increasing wherever an audit uncovers errors.
A summarized view of what a full-scope enterprise audit typically surfaces across 100+ providers.
Each area is reviewed at the chart level, against the same reference standards a payer or CERT contractor would use.
| Audit area | What we test | Reference standard | Why it matters at your scale |
|---|---|---|---|
| E/M leveling & MDM | Chart-level review of medical decision making and time-based leveling | AMA/CMS E/M guidelines, 95% accuracy benchmark | A one-level drift across 40 providers compounds into six figures a year |
| Modifier usage | Pattern analysis on modifiers 25, 59, 51, and 91 appended without supporting notes | NCCI edits, OIG Work Plan targets | Modifier 25 overuse is a named audit trigger, not a theory |
| ICD-10-CM & HCC specificity | Diagnosis-to-documentation match on RAF-relevant conditions | CMS-HCC model, ICD-10-CM guidelines | Every unspecified diagnosis on a Medicare Advantage panel is a RAF dollar left uncounted |
| NCCI & bundling edits | Column 1/Column 2 pairs and recurring unbundling patterns | CMS NCCI Policy Manual | A repeating pattern reads as a signal to CERT, not a one-off mistake |
| DRG validation | Principal diagnosis, CC/MCC capture, and discharge disposition accuracy | MS-DRG grouper logic | A missed MCC shifts an entire DRG payment, multiplied across every discharge |
The sampling logic follows what published AAPC benchmark surveys describe as standard for a mature audit program.
A stratified random sample, typically 10 to 25 charts per provider, weighted toward your highest-risk code sets.
Auditors score record-over-record and code-over-code, catching pattern-level drift a single chart would miss.
Every finding is tied to a dollar or risk value and benchmarked against the 95% accuracy standard.
A prioritized plan for coder education and payer-facing corrections, sequenced by impact.
Your findings report, impact summary, and remediation roadmap arrive ready to share with your board or a payer.
Every finding is checked against the current CMS NCCI edits, AMA CPT guidelines, and the active OIG Work Plan, the same sources a federal auditor would use.
No. You receive a chart-level findings report regardless of whether you engage BillingParadise beyond the audit. The report is built to be defensible in front of your board or a payer.
Both directions are reported. Overcoding creates compliance exposure. Undercoding, particularly on HCC-relevant diagnoses and E/M leveling, leaves legitimate reimbursement uncollected.
All chart review is conducted under a signed Business Associate Agreement. PHI is accessed only for the audit window and is not retained beyond the engagement.
A findings report with chart-level detail, a financial and compliance impact summary benchmarked against the 95% accuracy standard, and a prioritized remediation roadmap.
For groups with 15 or more providers. An AAPC-credentialed auditor scopes your review within one business day.
Work with medical billers who understand your EHR's billing process
