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CPC-OB · AHIMA · AAPC Certified Audit Team

OB/GYN Coding Audits That Find What You Are Missing

The average OB/GYN practice loses 15–30% of collectable revenue to coding errors. Our certified auditors find the missed codes, fix the modifier errors, and eliminate the OIG exposure — with a written corrective action report in 14 business days.

Free Coding Audit Assessment →Calculate Revenue Leakage
15–30%
Revenue Lost to Coding Errors
14 Days
Report Delivery Turnaround
5%
Error Rate Threshold for Action
$57.23
Cost to Rework One Denied Claim
HIPAA CompliantBAA AvailableCPC-OB CertifiedAHIMA CredentialedAAPC MemberMGMA Member
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15–30%
Average revenue lost to coding errors in OB/GYN
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26%
Surge in coding-related denials in 2025
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$50K–$200K
Typical missed revenue found in first audit
19%
In-network claims denied in 2025
Audit Types

Six Types of OB/GYN Coding Audits

Different practice situations call for different audit approaches. We recommend the right type for your specific risk profile.

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Prospective Audit

Claims reviewed BEFORE submission. Catches coding errors before they become denials or compliance exposure.

Best for: High-volume surgical services, new providers, after coding guideline changes
  • Zero denial risk on audited claims
  • Immediate revenue optimization
  • Real-time coder education
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Retrospective Audit

Claims reviewed AFTER submission and payment. Identifies patterns in past billing for correction and recovery.

Best for: Baseline compliance assessment, post-OIG inquiry, annual compliance review
  • Identifies systemic errors
  • Recovery opportunities on underbilled claims
  • Compliance documentation
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E/M Coding Audit

Focused review of Evaluation & Management codes (99202–99215) against 2024 AMA MDM guidelines.

Best for: Practices concerned about E/M level distribution, high denial rates on 99215
  • MDM documentation alignment
  • Level optimization
  • OIG risk reduction
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Surgical Coding Audit

Review of procedure codes, modifiers, and operative report documentation for all GYN surgical cases.

Best for: High-volume surgical practices, robotic surgery programs, laparoscopic specialists
  • Modifier error elimination
  • Bundling rule compliance
  • Operative report documentation review
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Modifier Usage Audit

Analysis of modifier application patterns across all claim types — identifying both missing and incorrect modifiers.

Best for: Practices with high CO-4 or CO-97 denial rates, after payer downcoding trends
  • Modifier matrix development
  • Denial root cause resolution
  • Correct unbundling documentation
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Charge Capture Audit

Review of the entire charge capture workflow from clinical encounter to claim submission. Identifies dropped charges.

Best for: Practices experiencing unexplained revenue drops, after EHR transitions
  • Zero dropped charges
  • Workflow optimization
  • Staff training targets
2024 AMA Update

E/M Coding Changes — Are You Still Billing Under Old Rules?

The 2024 AMA E/M revision changed how visit complexity is determined. Practices still coding by history/exam bullet counts are systematically underbilling.

Old Rule (Pre-2024)Current Rule (2024+)Revenue Impact for OB/GYN
History & Physical Exam drove E/M levelMedical Decision Making (MDM) drives E/M levelMany OB/GYN visits qualify for higher-level codes based on MDM alone
Detailed exam required for 99214+MDM with moderate complexity sufficient for 99214Postpartum visits with complications legitimately bill at 99214
Time-based had strict counting rulesTotal time including pre/post-visit work countsComplex prenatal counseling sessions support higher E/M levels
Bullet-counting for exam elementsClinical appropriateness standardDocumentation burden reduced; focus shifts to problem complexity
Risk Analysis

Upcoding vs Undercoding — Both Cost You

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Upcoding

Billing a higher-level code than documentation supports. Less common than undercoding, but far more dangerous.

Consequences:
  • OIG civil investigation
  • False Claims Act liability
  • CMS exclusion from Medicare/Medicaid
  • Mandatory repayment + penalties
  • State medical board review
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Undercoding

Billing a lower-level code than documentation supports. The most common coding error in OB/GYN — costing practices 15–30% of collectable revenue.

Common OB/GYN undercoding examples:
  • 99213 billed when 99214 supported
  • Missing modifier 22 on complex surgery
  • 59430 postpartum never billed
  • No J-code for IUD alongside 58300
  • LARC counseling codes omitted
OIG Risk Reduction

Top OIG Audit Targets in OB/GYN Billing

We audit for every OIG work plan priority relevant to OB/GYN — finding and fixing issues before federal auditors do.

Critical
E/M Upcoding
Billing 99215 without documentation supporting high complexity MDM. OIG consistently flags practices with >90th percentile 99215 rates.
High
Global Maternity Errors
Billing global package when visit threshold not met, or billing components inside a global period. Creates overpayment liability.
High
Unbundling Without Modifier
Billing CPT code pairs separately without modifier 59/X when NCCI edits indicate bundling required. Systematic unbundling without justification triggers RAC focus.
Medium
Modifier 22 Without Documentation
Using modifier 22 (increased procedural services) without operative report documentation of unusual complexity.
High
Duplicate Billing
Billing the same service twice — often happens when paper and electronic submission both process.
Low
Missing LARC Supply Codes
Not billing J-codes for IUD/implant devices alongside insertion codes. Underbilling — not a compliance risk, but a revenue risk.
Our Process

How Our Coding Audit Works

6 steps from record request to corrective action report — completed in 14 business days.

1

Record Request

We request a random statistical sample of 20–50 claims from the audit period — enough for statistical significance without operational burden.

2

Documentation Review

Our CPC-OB certified auditors review each claim against the underlying clinical documentation in your EHR.

3

Code Comparison

Billed codes are compared against audit-correct codes. Discrepancies are categorized: undercoded, overcoded, modifier error, missing code, or documentation gap.

4

Error Rate Calculation

We calculate your error rate by category. An error rate above 5% on any category warrants a corrective action plan.

5

Revenue Impact Analysis

We quantify the revenue impact of identified errors — both missed revenue (undercoding) and overpayment risk (upcoding).

6

Corrective Action Report

You receive a written report with specific findings, recommended code corrections, education priorities, and a 90-day corrective action plan.

Our Audit Team Certifications

CPC-OB
AAPC
OB/GYN specialty certification
CCS
AHIMA
Clinical coding specialist
CPC
AAPC
Certified professional coder
CPCO
AAPC
Certified compliance officer
CRC
AAPC
Risk adjustment coder
98.2%
First-Pass Rate
$4.2M
Revenue Recovered
200+
OB/GYN Practices Served
14 Days
Audit Report Delivery
FAQ

Coding Audit Questions

What is an OB/GYN coding audit?
An OB/GYN coding audit is a systematic review of your billing records comparing billed codes against clinical documentation. It identifies undercoding (lost revenue), upcoding (compliance risk), modifier errors, and documentation gaps. Our CPC-OB certified auditors review your claims, quantify the revenue impact of errors, and provide a written corrective action report.
How often should an OB/GYN practice audit?
Minimum annually, ideally quarterly. Immediate audits are warranted after: any change in billing staff, new service line introduction, increased denial rates, OIG or RAC audit notice, or major coding guideline changes. Prospective audits on surgical cases should be ongoing for high-volume surgical practices.
What is the difference between upcoding and undercoding?
Upcoding means billing a higher-level code than documentation supports — creating OIG risk and False Claims Act exposure. Undercoding means billing lower than documentation supports — the more common problem, costing OB/GYN practices 15–30% of collectable revenue annually. Both are identified and corrected in a coding audit.
How does a coding audit find missed revenue?
Auditors compare billed codes against documentation and identify cases where higher-level E/M codes were supported, additional procedures were performed but not coded, modifiers were missing, or supply codes (J-codes for IUDs) were omitted. Most practices find $50,000–$200,000 in recoverable revenue in the first audit.
What is a RAC audit and how do we prepare?
Recovery Audit Contractors (RACs) audit Medicare claims for improper payments. They focus on E/M upcoding, global maternity errors, and surgical bundling. A proactive internal coding audit corrects these issues before RAC auditors find them — and documents your compliance efforts as a mitigating factor if you do receive an audit notice.

Related Services

Denial ManagementRevenue Cycle ManagementGlobal Maternity BillingGYN Surgery CodingRevenue Leakage Calculator

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CPC-OB CertifiedWritten Report in 14 DaysNo ObligationHIPAA Compliant