HEALTHCARE BILLING & CODING COMPLIANCE CHECKLIST

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--- PATIENT DEMOGRAPHICS & INSURANCE VERIFICATION ---
[ ] Patient First Name
[ ] Patient Last Name
[ ] Patient Date of Birth
[ ] Patient Phone Number
[ ] Insurance Primary? (Yes, No)
[ ] Insurance Provider Name
[ ] Insurance Member ID
[ ] Insurance Group Number

--- PROCEDURE & DIAGNOSIS CODING (ICD-10) ---
[ ] ICD-10 Code Primary Diagnosis (Select Code, A00 – Cholera)
[ ] ICD-10 Code Secondary Diagnosis (if applicable) (None, I10 – Essential (primary) hypertension)
[ ] Supporting Documentation Notes (e.g., physician documentation, lab results)
[ ] Number of Diagnoses Documented
[ ] Date of Diagnosis Documentation
[ ] Physician Signature (Verify)

--- PROCEDURE CODING (CPT/HCPCS) ---
[ ] CPT/HCPCS Code
[ ] Procedure Description (from CPT/HCPCS)
[ ] Modifier Applied (if applicable) (No Modifier, -25, -50, -59, Other (Specify in Long Text))
[ ] Modifier Description (if 'Other' selected)
[ ] Units of Service
[ ] Service Date
[ ] Procedure Identifiers (e.g., Modality, Approach) (Endoscopic, Open, Radiological, Other)

--- MODIFIER APPLICATION ---
[ ] Modifier Applied (if any) (None, 26 - Professional Component, 50 - Reduced Fee, 59 - Distinct Procedural Level, LT - Left Side, RT - Right Side)
[ ] Modifier Justification (if applicable)
[ ] Modifier Percentage Adjustment (if applicable)
[ ] Applicable Billing Policy Adherence (Yes, No)
[ ] Date of Modifier Review

--- CHARGE ENTRY AND 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) (Manual, Automated)

--- CLAIM SUBMISSION & ELECTRONIC DATA INTERCHANGE (EDI) ---
[ ] Claim Control Number
[ ] Transmission Method (e.g., Direct, Clearinghouse) (Direct, Clearinghouse)
[ ] Number of Claims Submitted
[ ] Submission Date
[ ] EDI Format Version (e.g., 837 Professional) (837 Professional, 837 Health Care Claim, Other)
[ ] Functional Acknowledgement (FA) Status Codes (00 Accepted, 02 Accepted with corrections, 03 Rejected, Other)

--- DENIAL MANAGEMENT & APPEALS ---
[ ] Date of Denial Received
[ ] Denial Code (from payer)
[ ] Payer's Reason for Denial (copy from denial letter)
[ ] Assigned to Appeals Reviewer (Not Assigned, Reviewer 1, Reviewer 2, Reviewer 3)
[ ] Appeal Submission Date
[ ] Documentation Submitted with Appeal (description)
[ ] Appeal Status (Pending, Approved, Denied, Resolved, Abandoned)
[ ] Notes/Comments on Appeal Outcome

--- AUDITING & COMPLIANCE REVIEWS ---
[ ] Audit Start Date
[ ] Audit End Date
[ ] Number of Claims Reviewed
[ ] Number of Coding Errors Found
[ ] Coding Guideline Areas Reviewed (ICD-10 Official Guidelines, CPT Assistant, Medicare/CMS Guidance, Private Payer Policies)
[ ] Summary of Audit Findings
[ ] Auditor Signature
[ ] Overall Compliance Rating (Excellent, Good, Fair, Needs Improvement)

--- FRAUD AND ABUSE PREVENTION ---
[ ] Describe any recent unusual billing patterns observed.
[ ] Has any employee been identified for potential training on fraud prevention? (Yes, No)
[ ] 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) (Upcoding, Unbundling, Phantom Billing, Kickbacks, None of the above)
[ ] Date of last fraud risk assessment review
[ ] Reviewer Signature confirming fraud prevention protocols are in place

--- STAYING UPDATED ON REGULATORY CHANGES ---
[ ] Last Regulatory Update Review Date
[ ] Summary of Key Regulatory Changes
[ ] Source of Regulatory Information (e.g., CMS, AAPC, AHIMA) (CMS, AAPC, AHIMA, Internal Updates, Other)
[ ] Number of Continuing Education Credits Completed (Regulatory Updates)
[ ] Next Scheduled Regulatory Training Date

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