Audits are among the biggest concerns for healthcare providers operating under Medicare Part B. With CMS intensifying its oversight and technology making it easier to flag unusual billing patterns, practices must stay vigilant to avoid compliance headaches. Below are the top seven audit triggers in Part B billing, along with strategies to stay compliant and protect your revenue cycle.
1. Upcoding or Misuse of E/M Codes
Billing for higher-level services (e.g., 99215 instead of 99213) without proper documentation is one of the most common red flags for auditors. Evaluation & Management (E/M) services remain under close watch as CMS continues to refine its guidelines.
How to Stay Safe: Use detailed documentation templates, regularly train staff on code selection, and run internal audits to catch patterns of overuse. Consistency between clinical notes and selected codes is critical.
2. Excessive Use of Modifiers 25 and 59
While modifiers are essential tools, Modifier 25 (separately identifiable E/M service) and Modifier 59 (distinct procedural service) are often overused. This practice can raise suspicions of unbundling or billing for unnecessary services.
How to Stay Safe: Document clearly why the modifier was necessary and ensure clinical justification aligns with coding. Include supporting notes that distinguish why services were performed separately.
3. Medical Necessity Issues
Billing for services that are not medically necessary, or poorly documented as such, remain a top reason for claim denials and audits. Payers want to see that every billed service was reasonable and justified for the patient’s condition.
How to Stay Safe: Always tie services to the patient’s diagnosis codes (ICD-10). Review Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) regularly to ensure compliance.
4. High Utilization of Certain Services
Practices that bill significantly higher volumes of specific procedures compared to peers in their specialty often attract CMS scrutiny. For example, consistently billing for advanced imaging or complex procedures at higher-than-average rates can trigger audits.
How to Stay Safe: Benchmark your billing data against industry norms and investigate outliers. If high utilization is clinically justified, ensure documentation supports the frequency and necessity of services.
5. Telehealth Billing Errors
With telehealth expanding rapidly since 2020, CMS is tightening oversight on telehealth claims. Errors in place of service (POS) codes, originating site rules, and cross-state licensing have led to a significant number of denials and audits in the past few years.
How to Stay Safe: Keep up with annual telehealth policy updates, verify provider eligibility for telehealth billing, and double check telehealth specific codes before submission.
6. Improper Use of Incident-To Billing
Part B allows non-physician practitioners to bill services under a supervising physician via “incident-to” rules. However, incorrect application, such as billing without proper supervision or for non-qualifying services, frequently triggers audits.
How to Stay Safe: Ensure supervision requirements are met and documentation supports incident-to criteria. Train your clinical and billing teams to recognize when incident-to billing is appropriate.
7. Repeated Claim Resubmissions
Excessive resubmissions can flag billing systems and signal potential fraud or sloppy processes. While correcting and resubmitting denied claims is normal, frequent repeats for the same errors may lead to a raise in compliance risks.
How to Stay Safe: Invest in claim scrubbing tools to catch errors before submission. Develop a denial management process that includes root cause analysis to prevent recurring mistakes.
Staying Compliant with CMS
CMS’s audit triggers are designed to protect the integrity of Medicare funds. For providers, staying compliant requires a mix of accurate coding, documentation discipline, proactive auditing, and staff training. Practices that implement strong compliance programs will not only avoid CMS’s radar but also maximize clean claim rates and safeguard revenue.
At MBNC, we help practices stay ahead of CMS compliance requirements through proactive claim audits, accurate coding support, and denial prevention strategies. Partner with us today, to safeguard your revenue cycle and reduce audit risks.
