E/M leveling, AWV documentation compliance, MDM scoring, modifier and NCCI edit risk — reviewed at the chart level by a consultant with direct operator-level coding audit experience. Fixed-fee across all three tiers.
Every audit tier applies the same six-area methodology — scope determines how many charts receive the review, not what the review covers. All findings are tied to a specific CPT code, documentation standard, or regulatory citation.
The single highest-audit-risk area in outpatient billing. E/M level is re-scored against the 2023 AMA guidelines using Medical Decision Making complexity — number and complexity of problems, data reviewed, and risk of complications. Overcoded and undercoded charts both flagged.
Annual Wellness Visit billing (G0438, G0439) requires a health risk assessment, a personalized prevention plan, and specific screening components. Missing documentation elements are the most common AWV denial driver and a recurring OIG audit target across all specialties.
Modifier 25 (separate E/M on the same day as a procedure), Modifier 59 (distinct procedural services), and bilateral modifiers each carry specific documentation requirements that auditors examine. Frequency above specialty-specific thresholds is flagged with exposure calculations.
National Correct Coding Initiative edits define which CPT code combinations cannot be billed together without a modifier override. Common NCCI violations — particularly in high-procedure specialties — result in automatic claim denials or post-payment audits.
Since 2023, E/M visits may be billed based on total time or Medical Decision Making. Charts using time-based billing are reviewed for contemporaneous documentation of total time spent and the activities included in the time calculation.
Standard and Comprehensive tiers include a payer-specific review layer — Medicare LCD requirements, MAC-specific documentation policies (Palmetto GBA for Georgia providers), and commercial payer coverage policies where relevant to the audited CPTs.
Choose based on your practice size and how much chart coverage you need. All three tiers apply the same six-area audit methodology. The Snapshot is designed for solo providers doing a first-time review; Standard and Comprehensive are sized for group practices and annual compliance programs.
The three tiers above cover general E/M and AWV billing. The full catalog includes specialty-focused audits that go deeper on specific code sets — available after a discovery call.
Deep-dive AWV audit — G0438 Initial and G0439 Subsequent documentation completeness, Health Risk Assessment scoring, personalized prevention plan adequacy, and screening referral documentation. Priced separately at $750–$1,500. High-conversion: AWV is a recurring OIG audit target and a high-margin service for most primary care practices.
Psychotherapy session documentation (90837, 90834, 90832), E/M in psychiatric settings, interactive complexity add-on (90785), and telehealth billing compliance post-PHE. Includes review against the OIG's active mental health billing audit priorities.
Chronic Care Management billing (99490, 99491) — consent documentation, 20-minute threshold tracking, care plan requirement, clinical staff qualification, and same-day billing restrictions. CCM is a high-revenue line item with specific documentation requirements most practices under-document.
Speech-language pathology Medicare Part B billing (92507, 92521–92524) — KX modifier threshold documentation, functional limitation G-codes, Medicare Benefit Policy Manual Chapter 15 compliance, and progress note adequacy. Specifically designed for SLP practitioners billing independently or in a SNF Part B context.
Confirm tier, provider count, and chart selection criteria. We provide a chart selection template — you pull the records, redact patient identifiers at your discretion, and transmit via secure file transfer.
Each chart is reviewed against the six audit areas by a consultant with direct coding audit experience in a multi-provider RCM environment. Every finding is documented with the specific CPT code, the documentation standard cited, and the re-scored level where applicable.
Institutional-voice findings memo (Snapshot) or full audit report (Standard / Comprehensive) delivered via secure file transfer. All findings include the regulatory citation, overpayment or underpayment direction, and recommended corrective action.
Comprehensive tier includes a 60-minute findings walkthrough with your billing manager, practice administrator, or compliance officer. We prioritize findings by dollar exposure and training urgency, and recommend whether a follow-up audit is warranted.
The Snapshot is designed to be the lowest-friction entry point — 10 charts, 5 business days, $495. Most practices that complete a Snapshot have a clear answer on whether a deeper audit is warranted within a week of the first conversation.
If you're a group practice or want provider-level breakout, go straight to Standard. If you've never had a coding review, start with the Snapshot and let the findings drive the next step.
Or email hello@prognosisconsulting.com · Response within 1 business day