A practical checklist for running an internal coding audit, covering the highest-risk areas in OB/GYN billing.
A coding audit doesn't need to review every chart to be effective — a focused, representative sample targeting the highest-risk areas catches most systemic issues without consuming weeks of staff time.
Step 1: Pull a Representative Sample
Aim for a mix across providers, visit types, and payers rather than reviewing only the easiest or most recent charts. A sample skewed toward one provider or one payer will miss issues specific to others.
Step 2: Check Global vs. Itemized Maternity Classification
This is consistently one of the highest-error areas — see our full comparison of [itemized vs. global maternity billing](/blog/itemized-vs-global-maternity-billing) for the exact criteria to check against.
Step 3: Review High-Dollar Surgical Codes First
Surgical coding errors carry more financial weight per instance than routine visit errors. Prioritize reviewing your highest-volume GYN surgical codes — our [gynecological surgery coding mistakes](/blog/gyn-surgery-coding-mistakes) guide lists the most common errors to check for specifically.
Step 4: Verify O-Code Trimester Specificity
A quick scan for unspecified or missing trimester digits, as covered in our [ICD-10 O-codes guide](/resources/icd10-o-codes), often surfaces an easy, high-volume fix.
Step 5: Cross-Check Modifier Usage
Confirm modifiers like 22 (increased complexity) and telehealth modifiers 95/GT are applied correctly and consistently, not just present or absent at random.
Key Takeaways
- ›A focused, representative sample is more useful than an exhaustive review
- ›Maternity classification and surgical coding are the highest-risk areas to check first
- ›Run this audit quarterly, not just after a denial spike
If you'd rather have this done independently and objectively, our [coding audit services](/coding-audits) apply this exact checklist with an outside perspective that's often better at catching blind spots than an internal review.