In today’s rapidly evolving healthcare environment, coding audits have become a cornerstone of compliance and revenue integrity. The days of infrequent, retrospective reviews are behind us. Payers are now using advanced analytics, natural language processing (NLP), and artificial intelligence (AI) to identify documentation and coding anomalies with increasing speed and precision.
As the landscape continues to shift, health information (HI) Programming note:
Listen live when Angela Comfort cohosts Talk Ten Tuesday with Chuck Buck, 10 am Eastern.
professionals must move beyond reactive audit defense and adopt proactive strategies that anticipate payer focus and regulatory change.
Audit triggers are no longer limited to high-dollar claims or Diagnosis-Related Group (DRG) shifts. In 2025, both public and private payers are scrutinizing clinical validation issues, risk score anomalies in value-based contracts, and documentation that lacks specificity or clinical support. Diagnoses such as sepsis, encephalopathy, acute kidney injury, and malnutrition remain high-risk targets due to frequent documentation deficiencies.
In the outpatient space, payers are focusing on audio-only telehealth visits, evaluation and management (E&M) leveling, and prolonged service codes. The common thread is that auditors are increasingly equipped with AI-driven tools capable of detecting patterns across vast datasets, meaning that even subtle inconsistencies can trigger review.
Documentation quality and coding specificity are directly tied to audit risk. Discrepancies between what is documented in the electronic health record (EHR) and what is reported on claims can lead to costly takebacks, reputational damage, and heightened scrutiny from regulators.
The misuse of unspecified codes, failure to connect diagnoses with supporting clinical indicators, and inconsistent terminology are persistent red flags. The expansion of value-based care models adds further complexity, as incomplete or imprecise documentation can impact both financial performance and quality scoring.
Leading organizations are adopting an audit resilience mindset, rather than simply reacting to payer findings. Strategic internal audits, particularly those targeting high-risk DRGs and outpatient encounters, enable early detection of vulnerabilities. These audits should assess not just coding accuracy, but the clinical validity of the documentation itself. Education is equally important; programs should be case-based, data-driven, and tailored to the clinical specialties they serve, ensuring that providers understand how their documentation influences audit outcomes.
Modern audit readiness is supported by technology. Predictive analytics can help identify potential denials before a claim is submitted. EHR-integrated tools can prompt for greater specificity at the point of care. Coding accuracy platforms with real-time feedback loops help reduce documentation gaps.
Additionally, centralized audit tracking systems enable the identification of trends and root causes, ensuring that lessons learned from one audit are applied across the organization.
Health information (HI) professionals are uniquely positioned to lead organizational audit readiness efforts. Their work now extends beyond coding oversight to include enterprise-wide education, documentation process optimization, and the evaluation of audit technologies. HI leaders must bridge communication gaps between clinicians, compliance teams, and revenue cycle leadership, ensuring that policies are informed by both regulatory guidance and operational realities.
The future of coding audits is complex, technology-driven, and fast-moving. Organizations that succeed will be those that anticipate audit risks, invest in proactive education, and leverage tools to support defensible documentation.
As healthcare continues to prioritize value-based models and data-driven oversight, HI professionals have a pivotal role in protecting compliance, revenue integrity, and the quality of patient care.
Programming note:
Listen live today when Angela Comfort cohosts Talk Ten Tuesday with Chuck Buck, 10 am Eastern.
EDITOR’S NOTE:
The opinions expressed in this article are solely those of the author and do not necessarily represent the views or opinions of MedLearn Media. We provide a platform for diverse perspectives, but the content and opinions expressed herein are the author’s own. MedLearn Media does not endorse or guarantee the accuracy of the information presented. Readers are encouraged to critically evaluate the content and conduct their own research. Any actions taken based on this article are at the reader’s own discretion.
Last week I spoke at the annual revenue integrity symposium sponsored by the National Association of Healthcare Revenue Integrity. And I really enjoy that conference;
Healthcare compliance just got a lot more complicated. We’re not dealing with traditional whistleblowers anymore – the ones who needed inside access to spot problems.
Please log in to your account to comment on this article.
Denials continue to delay reimbursement, increase administrative burden, and threaten financial stability across healthcare organizations. This essential webcast tackles the root causes—rising payer scrutiny, fragmented workflows, inconsistent documentation, and underused analytics—and offers proven, data-driven strategies to prevent and overturn denials. Attendees will gain practical tools to strengthen documentation and coding accuracy, engage clinicians effectively, and leverage predictive analytics and AI to identify risks before they impact revenue. Through real-world case examples and actionable guidance, this session empowers coding, CDI, and revenue cycle professionals to shift from reactive appeals to proactive denial prevention and revenue protection.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.
Federal auditors are zeroing in on Inpatient Rehabilitation Facility (IRF) and hospital rehab unit services, with OIG and CERT audits leading to millions in penalties—often due to documentation and administrative errors, not quality of care. Join compliance expert Michael Calahan, PA, MBA, to learn the five clinical “pillars” of IRF-PPS admissions, key documentation requirements, and real-life case lessons to help protect your revenue.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
