Performing Prospective Coding and Documentation Reviews for Your Practice

Medical practices should conduct quarterly prospective coding and documentation reviews.  A designated certified coder or internal compliance officer would review the claims before they are submitted to the payer for appropriateness of coding and documentation.   A prospective review will ensure the physician is submitting appropriately coded claims according to Current Procedural Terminology (“CPT”) guidelines and payer payment policies, as the physician is ultimately responsible for claims submission, even if a billing service or clearinghouse is used for claims submission to payers.  

Should the audit reveal a pattern of repeated coding, documentation and/or billing errors, physician education should be provided.   Additionally, the necessary steps should be taken to ensure these errors don’t recur.  


Maureen Doherty is a Health Care Services Group Consultant providing coding, billing and insurance claims processing services to a variety of multi-specialty practices.

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