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THIS WEEK IN PRACTICE |
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Last week we covered E&M coding and the documentation that supports it. This week: the OIG Work Plan — the federal government’s published list of audit priorities for the year. Understanding what’s on the Work Plan is not about paranoia. It is about knowing which billing patterns are under active scrutiny so you can confirm your documentation and processes can withstand review. |
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DEEP DIVE | |||||||||||||||||||||||||||||
What the OIG Work Plan Means for Independent Practices in 2026 | |||||||||||||||||||||||||||||
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The Office of Inspector General publishes and updates its Work Plan throughout the year at oig.hhs.gov. The Work Plan identifies the specific areas where OIG auditors will be examining Medicare and Medicaid billing — the diagnoses, procedures, and billing patterns that will receive scrutiny in the coming months. Here is what this looks like in practice. A 4-provider cardiology practice ran an internal audit of their modifier -25 usage after seeing it on the OIG focus list. They pulled 20 claims where -25 was billed with an in-office procedure. Finding: 6 of 20 (30%) had documentation that did not support a separately identifiable E&M service — the note referenced the same condition as the procedure with no additional evaluation. At $103 per 99213 and 150 modifier -25 claims per month, the exposure was approximately $55,000 annually in potentially recoupable payments. They retrained providers on documentation requirements and re-audited 60 days later: error rate dropped to 5%. The voluntary self-audit documentation became their strongest defense asset.
Focus on the top 2–3 areas most relevant to your practice. A voluntary self-audit is your strongest defense — documented findings with corrective action demonstrate good faith. For independent practices, the Work Plan serves two purposes: it identifies the billing areas where your documentation needs to be strongest, and it provides advance notice of audit targets that allow you to conduct internal self-audits before an external one occurs. The 2026 Work Plan includes several items of direct relevance to independent practices. Here are the five that matter most: E&M code levels — particularly 99214 and 99215 billed at rates above specialty norms. The OIG has flagged this persistently. If your practice’s distribution of 99214 and 99215 is significantly above the national distribution for your specialty, your coding patterns may be flagged. The correct response is not to code down — it is to ensure your documentation unambiguously supports every higher-level code you bill. Telehealth billing compliance. Following the expansion of telehealth during the COVID public health emergency and subsequent policy changes, OIG is examining whether telehealth claims meet current documentation requirements, use the correct place of service codes, and involve patients in eligible locations. Practices with significant telehealth volume should audit a random sample of telehealth claims from the past 12 months. Incident-to billing. Services billed under the supervising physician’s NPI must meet specific conditions: the physician must have initiated the plan of care, the physician must be physically present in the office suite during the non-physician service, and the service must be for an established condition. Incident-to billing is a frequent audit target because the requirements are not always well understood. Modifier 25 — significant, separately identifiable E&M on the same day as a procedure. OIG has flagged practices that append modifier 25 routinely to E&M codes billed on the same date as procedures, without adequate documentation that the E&M was truly separate from the pre/post work of the procedure. Mental health billing accuracy — particularly time-based psychotherapy codes and crisis service billing. Practices providing behavioral health services should review documentation for time-based codes, confirming that notes reflect the specific start and stop time of the service. |
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THREE ACTION STEPS THIS WEEK | ||
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Complete each step before next Tuesday. | ||
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FIVE THINGS WORTH KNOWING | ||||||||||
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BILLING CORNER | |
How to Conduct an Internal Coding Audit Before an | |
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An internal coding audit doesn’t require a compliance consultant or a formal program. It requires a random sample, a checklist, and the discipline to document what you find.
Step 1: Select your sample. Pull 30 claims at random from the past 90 days — 15 from your highest-volume E&M code and 15 from the next highest. Random means random: do not cherry-pick clean claims. Step 2: Pull the documentation. For each claim, pull the clinical note for that date of service. Step 3: Apply the coding criteria. For E&M codes: does the documented MDM or total time support the billed code level? For procedure codes: does the operative or procedure report describe the service billed? For any claims with modifier 25: does the note document a significant, separately identifiable E&M? Step 4: Calculate your accuracy rate. Divide the number of claims that fully meet the coding criteria by the total number reviewed. A rate above 95% indicates strong documentation practices. 90–95% suggests specific areas for improvement. Below 90% suggests a systematic documentation problem requiring provider education and template revision. Step 5: Document and act. Write a one-page audit summary: sample size, findings, accuracy rate, and corrective actions. File it. This document is your evidence of a functioning compliance program. |
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Internal Coding Audit Documentation Template Audit date: [Date] Auditor: [Name/Title] Sample: [X] claims reviewed from [Date Range] for [Provider Name] Focus area: [OIG category being audited] Findings: [X] of [X] claims met documentation requirements. [X] claims had [specific deficiency]. Error rate: [X]% Benchmark: Below 5% = acceptable. 5–10% = education needed. Above 10% = immediate corrective action. Corrective action: [Specific fix, responsible person, deadline] Follow-up audit date: [30–60 days from findings] Key: Keep this document in your compliance file. If you are ever audited, voluntary self-audits with documented corrections are your strongest defense. |
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COMPLIANCE WATCH | |
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PEOPLE & PRACTICE |
Building a Compliance Culture Without Making |
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Compliance programs in small independent practices often fail not because the practice doesn’t care about compliance, but because the framing creates anxiety rather than accountability. ’We need to make sure we don’t get in trouble’ is a compliance program built around fear. It produces over-caution, under-coding, and staff who avoid flagging problems because they’re afraid of what the answer will be. A more effective framing: compliance is about doing things right so we can defend what we do. That means billing accurately for the clinical complexity we actually provide, documenting what we actually do, and having a process for identifying and correcting mistakes before they become patterns. Concretely: hold a 30-minute annual compliance review with your billing team and provider(s). Cover three things: what the current OIG priorities are; what your internal audit found this year; and what changes you’re making to documentation or billing processes based on that audit. Make it informational, not accusatory. Document that it happened. That 30-minute meeting, documented with a one-page summary of what was covered, is more compliance program than 90% of independent practices have — and it materially reduces your exposure if you’re ever subject to review. |
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ASK THE PULSE | ||||||
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ONE MORE THING |
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The OIG Work Plan is public, updated regularly, and available for free at oig.hhs.gov. It takes about 20 minutes per year to review the items relevant to your specialty. Most practices never look at it. The ones that do have 20 minutes of forewarning that others don’t. See you next Tuesday. |
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The Practice Pulse · Issue 10 · Every Tuesday at 7 AM |