09/02/2026
🚨 CODING & COMPLIANCE ALERT: Billing Audits Are Getting More Attention
If you read Monday's AHIMA SmartBrief, you may have noticed the headline: “CMS, insurers intensify billing audits.”
The SmartBrief highlighted a recent Medscape article by Leslie Kane, MA, reporting that CMS, Medicare contractors and commercial insurers are increasing efforts to identify and recover potential overpayments. According to the article, Medicare Advantage is an important area of focus, with CMS increasing coding resources and payers using data analytics to identify billing and documentation patterns that may warrant review.
🔎 What could attract auditor attention?
The Medscape article identifies several areas HIM, coding, compliance and revenue cycle professionals should keep on their radar:
• E/M coding patterns — particularly frequent use of higher-level services compared with specialty benchmarks
• Modifier 25 — documentation must support a significant, separately identifiable E/M service when reported with another procedure or service
• “Incident to” billing — Medicare requirements are specific and must be met
• Coding outliers — patterns outside expected specialty benchmarks may prompt additional scrutiny
• Telehealth — changing coverage, billing and documentation requirements require continued attention
• Medicare Advantage/HCC risk adjustment — reported diagnoses need appropriate documentation and clinical support
📊 An outlier does not automatically mean incorrect coding.
That is an important distinction. Coding should reflect the care actually provided and be supported by the medical record. Fear of an audit should not lead organizations to automatically downcode appropriately documented services.
✅ What can organizations do now?
Consider regular internal coding audits, monitor coding and utilization trends, compare patterns with available benchmark data, stay current with CMS and payer policies, and routinely review the HHS-OIG Work Plan for areas receiving federal attention.
Communication matters, too. Providers, coders, CDI, compliance, auditors and revenue cycle teams should work together so documentation and coding requirements are understood before an audit request arrives.
💡 IaHIMA Takeaway
Audit readiness isn't about coding defensively. It's about coding accurately, documenting clearly and being able to support what was reported.
📚 Featured in: AHIMA SmartBrief, “CMS, insurers intensify billing audits.”
📖 Original article: Leslie Kane, MA, “Watch Out! A Coding and Billing Audit May Be Coming Your Way,” Medscape, August 28, 2026.
