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Healthcare Billing & Coding Compliance Checklist

Avoid claim denials & maximize revenue! Our Healthcare Billing & Coding Compliance Checklist ensures accuracy, minimizes risk, and keeps your practice audit-ready. Download now for streamlined processes and peace of mind.

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Patient Demographics & Insurance Verification

1 of 10

Ensuring accurate patient information and insurance coverage before services are rendered.

Patient First Name

Patient Last Name

Patient Date of Birth

Patient Phone Number

Insurance Primary?

Insurance Provider Name

Insurance Member ID

Insurance Group Number

Procedure & Diagnosis Coding (ICD-10)

2 of 10

Verification of correct diagnosis codes based on medical documentation.

ICD-10 Code Primary Diagnosis

ICD-10 Code Secondary Diagnosis (if applicable)

Supporting Documentation Notes (e.g., physician documentation, lab results)

Number of Diagnoses Documented

Date of Diagnosis Documentation

Physician Signature (Verify)

Procedure Coding (CPT/HCPCS)

3 of 10

Ensuring proper coding of procedures performed, adhering to guidelines.

CPT/HCPCS Code

Procedure Description (from CPT/HCPCS)

Modifier Applied (if applicable)

Modifier Description (if 'Other' selected)

Units of Service

Service Date

Procedure Identifiers (e.g., Modality, Approach)

Modifier Application

4 of 10

Accurate use of modifiers to reflect specific circumstances of the service.

Modifier Applied (if any)

Modifier Justification (if applicable)

Modifier Percentage Adjustment (if applicable)

Applicable Billing Policy Adherence

Date of Modifier Review

Charge Entry and Documentation

5 of 10

Properly entering charges and verifying supporting documentation.

Total Charges Entered

Detailed Description of Services Rendered (for clarity)

Units of Service Billed

Date of Service

Biller Signature (Confirmation of Accuracy)

Charge Entry Method (Manual/Automated)

Claim Submission & Electronic Data Interchange (EDI)

6 of 10

Verification of claim format and adherence to EDI standards.

Claim Control Number

Transmission Method (e.g., Direct, Clearinghouse)

Number of Claims Submitted

Submission Date

EDI Format Version (e.g., 837 Professional)

Functional Acknowledgement (FA) Status Codes

Denial Management & Appeals

7 of 10

Tracking and addressing claim denials with appropriate appeals.

Date of Denial Received

Denial Code (from payer)

Payer's Reason for Denial (copy from denial letter)

Assigned to Appeals Reviewer

Appeal Submission Date

Documentation Submitted with Appeal (description)

Appeal Status

Notes/Comments on Appeal Outcome

Auditing & Compliance Reviews

8 of 10

Regular audits to ensure ongoing compliance with billing and coding regulations.

Audit Start Date

Audit End Date

Number of Claims Reviewed

Number of Coding Errors Found

Coding Guideline Areas Reviewed

Summary of Audit Findings

Auditor Signature

Overall Compliance Rating

Fraud and Abuse Prevention

9 of 10

Identifying and preventing fraudulent billing practices.

Describe any recent unusual billing patterns observed.

Has any employee been identified for potential training on fraud prevention?

Number of referrals received from a single referring physician in the last month:

Which of the following are potential red flags for fraud? (Select all that apply)

Date of last fraud risk assessment review

Reviewer Signature confirming fraud prevention protocols are in place

Staying Updated on Regulatory Changes

10 of 10

Maintaining awareness of current coding guidelines and regulatory updates.

Last Regulatory Update Review Date

Summary of Key Regulatory Changes

Source of Regulatory Information (e.g., CMS, AAPC, AHIMA)

Number of Continuing Education Credits Completed (Regulatory Updates)

Next Scheduled Regulatory Training Date

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