CMS and private insurers are ramping up coding and billing audits, and physicians are feeling the pressure. CMS has pledged to hire more medical coders — focusing heavily on Medicare Advantage Plans, which now cover 55% of Medicare enrollees — to identify improper payments. But even providers outside Medicare Advantage aren't in the clear: commercial insurers and Recovery Audit Contractors are actively reviewing claims too.

Common audit triggers include billing more high-level E/M codes (like 99214 or 99215) than peers in your specialty, overuse of modifier 25, improper "incident to" billing for NPs and PAs, and telehealth documentation gaps. Experts stress that even well-intentioned physicians can run afoul of increasingly complex payer rules.

Key Takeaways:

• Conduct an internal self-audit annually and consider bringing in an outside auditor
• Monitor the OIG Work Plan each year to anticipate upcoming audit focus areas
• Never alter notes or records if you receive an audit notice — and call a healthcare attorney immediately
• Avoid both overcoding and undercoding; always document the care actually provided

Why it matters: With $814.1 million recovered by HHS-OIG in just six months and a $556 million Kaiser Permanente settlement making headlines, the stakes for coding errors — intentional or not — have never been higher. Physicians who stay proactive can significantly reduce their risk.