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Documentation and Coding/Audit

Documentation and Coding Compliance / Audit

Revenue cycle integrity starts at the front desk and ends with complete and proper payment. Don’t underestimate the power of the front desk. They are the patients first impression of your practice. Let our subject matter experts work with your staff to establish revenue cycle integrity and minimize the risk of improper payments. Proper payment relies on verifying coverage, authorizations, referrals when applicable, proper coinsurance collection and submission of clean claims.

Documentation and risk mitigation with EMR charting is high on the list or risk for providers. Adequate templates and workflow can streamline processes and ensure that documentation is timely and complete. Ask us about workflow and other strategies to help you maximize face to face time with patients and minimize the time it takes to chart.


Our talented team of certified professional coders and medical auditors are experienced experts in the industry and cover all specialties. We match your reviewer with your specialty. Our documentation and coding audit approach follows a structured methodology designed to identify existing and potential coding and documentation issues that may impact revenue and/or compliance risks. 

What we offer:

Documentation & Coding chart reviews
Pre-billing documentation & coding validation services
Prospective & retrospective audits
RAT STATS statistically valid sampling
Kovel & attorney client privilege engagement

In addition to conducting documentation and coding audits we provide one on one, and group, post audit provider education

Our certified training experts have over 34 years’ experience effectively helping providers and staff understand how to practically meet the documentation guidelines in their day to day workflow. Our training is designed to be flexible and tailored based on your organizational needs and identified areas for targeted improvement. Once your audit is complete, we will work with you to evaluate appropriate training recommendations and the most cost-effective method for your organization. Training can be delivered in a variety of methods depending on your preferences and budget.


Today’s healthcare environment is more complex than ever. There are a multitude of regulations and guidelines that providers are expected to know and follow. It is hard enough to keep up with the day to day operations, patient care and keeping the practice financially viable. Let us help get you on the right track so that you can navigate and avoid the perils that can sneak up and bite you when you least expect it.

Providers need to be proactive now more than ever. Developing a culture of compliance starts at the top. It is the only way an organization or practice can ever hope to develop an effective and ethical program. We can teach compliance, but we cannot teach you ethics. Everyone in the practice or organization is responsible for compliance and should understand that it is a condition of employment.

Here’s what we offer:

Compliance program development and implementation support
Tutorial and mentor support staff and boards
Interim compliance officer
NYS mandatory compliance program adoption & certification support
Corporate integrity agreement compliance support
90 day program implementation
IRO services
Reporting requirements
Documentation, coding, billing compliance

We have the right people and the right tools to help you develop, implement, and manage an effective compliance program. Do not be intimidated, if you are not sure where or how to get started. Call us today to ask how we can help.


Practice management services include:

Revenue Cycle Integrity
EMR workflow, template design, and implementation
Practice and staff assessments and workflow strategies
Training and Education
PCMH accreditation

If you need additional practice management support that we do not have listed, please let us know. We are happy to customize a plan specific to your need.


Training is an integral and required component of an effective compliance program. It is one of our most important forms of communication with employees. How can we expect our staff to excel and succeed if we do not teach them what is expected of them?

There are three basic steps for setting up educational objectives:

Determining who needs training (both in coding and billing and in compliance);
Determining the type of training that best suits the practice’s needs (e.g., seminars, in-service training, self-study or other programs); and
Determining when and how often education is needed and how much each person should receive.

According to the OIG there are two goals a practice should strive for when conducting compliance training:

  1. All employees will receive training on how to perform their jobs in compliance with the standards of the practice and any applicable regulations; and
  2. Each employee will understand that compliance is a condition of continued employment. Training should emphasize that following the standards and procedures will not get a practice employee in trouble but violating the standards and procedures may subject the employee to disciplinary measures. It is advisable that new employees be trained on the compliance program as soon as possible after their start date and employees should receive refresher training on an annual basis or as appropriate.

Our subject matter experts will customize training for your organization and offer a variety of educational topics including:

Fraud,waste, abuse and errors
Documentation & coding compliance
Risk adjustment fundamentals
Compliance programs A-Z
Compliance training for your Board
Practice management A-Z

The OIG recommends that there be at least an annual training program for all individuals involved in the coding and billing aspects of the organization or practice. Let our experts assist you in developing your training plan and providing educational in-services.