Medical Billing and Coding Editing and Proofreading Services

Medicare sorts its fee-for-service payment errors into five categories. Four of the five definitions divide evenly on one point, which is whether the record settled anything. Incorrect coding and medical necessity errors are both defined by what the record supports. Incorrect coding is recorded where "Medical documentation supports" findings such as "A different code than what was billed."¹ Medical necessity is recorded where it supports that "Services billed were not medically necessary based upon Medicare coverage and payment policies."¹

Two others are defined by what could not be established. A no documentation error is recorded where "The provider or supplier fails to respond to repeated requests for the medical records."¹ An insufficient documentation error is recorded where "The documentation is insufficient to determine whether the claim was payable."¹ Three circumstances are listed under that definition, and one of them is that "A specific documentation element, that is required as a condition of payment, is missing."¹ The fifth category is Other, covering an improper payment that fits none of the rest.¹

Where the larger share of the money sits

For 2025 the agency put insufficient documentation at 53.0 percent of overall improper payments and no documentation at a further 12.0 percent.² Medical necessity accounted for 15.3 percent, incorrect coding for 11.1 percent, and Other for 8.5 percent.² The two categories defined by what could not be established are together larger than the other three put together.

CMS put the estimated Medicare fee-for-service improper payment rate for 2025 at "6.55%, or $28.83 billion."³ Medicaid and CHIP are measured separately, and the agency reports the same category in both. Of the Medicaid improper payments that year, 77.17 percent "were the result of insufficient documentation, which is generally not indicative of fraud or abuse."³ The CHIP figure is 56.07 percent, described in the same words.³

What a missing element looks like on the page

The Office of Inspector General reviewed psychotherapy services furnished in the first year of the public health emergency. Of 216 sampled enrollee days, it reported that for 128 of them providers did not meet Medicare requirements.⁴ The example the report gives is that "psychotherapy time was not documented."⁴ The report separately records enrollee days on which providers did not meet Medicare guidance, and the example given there is that "providers' signatures were missing."⁴ Both are examples rather than a closed list.

An audit of one Medicare Advantage contract covered payment years 2018 and 2019. It reported that "For 232 of the 286 sampled enrollee-years, medical records did not support the diagnosis codes and resulted in $830,334 in net overpayments."⁵ The sample was drawn from diagnoses the auditors had grouped as at higher risk of miscoding.⁵ A proportion measured that way does not describe coding at large.

The regulation makes the writing a condition of payment

Six basic conditions appear in 42 CFR 424.5(a), and further conditions sit elsewhere in that part.⁶ One of the six is headed "Sufficient information."⁶ It requires that "The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment."⁶

Hospitals participating in Medicare work under a condition of participation about the entries themselves. 42 CFR 482.24(c)(1) requires that "All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form."⁷ The same sentence continues, "by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures."⁷ Five properties are named there, and the last of them carries a further requirement about who supplies it.

A missing or illegible signature has its own guidance. CMS states that "We accept a signature attestation for all medical documentation except orders when required."⁸ The attestation "must be associated with a medical record and created by the record's author."⁸ Attestations may be considered regardless of when they were created, "unless the regulation or policy indicates that the signature must be in place before a given event or date."⁸ The same guidance states that "an attestation can't be used to backdate the plan of care."⁸

Documents we never see, and documents we do

Medical necessity, the level a service reached, and the code that describes it are determined by the clinician and the coding staff. We make none of those determinations. We do not ask a client for identifiable patient records, and we do not work on them.

Templates and their prompts, internal documentation guidance, payer policy summaries, and appeal letters are a different kind of document, and they are the ones we edit. Where a policy names an element and the template carries no prompt for it, the omission shows when the two are laid out together. Where an appeal letter states a total and itemizes it, the check is arithmetic and nothing else. What a client sends stays between the client and the editor.

Two retention rules can reach one episode of care. At a participating hospital, medical records "must be retained in their original or legally reproduced form for a period of at least 5 years."⁷ A separate rule reaches providers and suppliers furnishing covered ordered, certified, referred, or prescribed Part A or B services, items, or drugs. It reaches as well a physician or, when permitted, an eligible professional who orders, certifies, refers, or prescribes them.⁹ Each maintains documentation relating to those written orders, certifications, referrals, prescriptions, and requests for payments for seven years from the date of service.⁹