Healthcare and life sciences / Managed BPO
Medical coding audit support for previously coded charts
Actigy BPO helps billing teams recheck previously coded professional-fee encounters. A qualified reviewer compares the original coding with the chart and agreed rules, then records each finding for your coding lead. Agree the reviewer’s specialty experience and access permissions before sharing records.
Agree the scope, access and reviewer before a paid pilot.
- Encounter
- Completed coding selected for review
- Finding
- Modifier support absent from available chart
- Record
- Evidence gap and applicable rule version
- Decision
- Coding lead adjudicates the finding
A worked example of the record and decision flow. Not a client case or promised result.
The work. The handoff. Your decision.
A defined workflow in your systems
US medical billing companies, professional-fee coding managers and multi-site provider groups with a completed coding queue, documented payer rules and permission to use reviewers in the proposed location.
You provide
Previously coded encounters, relevant chart and agreed rule version.
Actigy BPO prepares
Finding log with code, modifier, source evidence and review status.
You retain
Provider queries, claim changes and final coding decisions.
Decision owner: Client coding lead. Confirm this role and the escalation contact in the written scope.
Service detail / 01
When does a separate coding review make sense?
A billing company may need a second reviewer after a coder handover, a change in specialty mix, or a rise in coding-related denials. The unit of work is a previously coded encounter. For assigning codes to a fresh queue, use our medical coding outsourcing service. For an unpaid claim that needs a payer response, use denial management.
- Check a defined sample of professional-fee encounters for one specialty before extending the scope.
- Trace whether a repeated finding relates to code selection, a modifier, documentation, a coding-policy question or a payer-specific rule.
- Escalate any question that requires clinical interpretation to the provider or client-designated clinical owner.
Service detail / 02
How do you choose the sample and score the review?
Agree the review period, eligible chart population and unit of analysis. For a baseline, draw a documented sample from that population. To investigate a specific problem, build a separate targeted sample and report it separately. A high-risk sample cannot establish the error rate of the entire coding operation.
- Record the applicable code-set version, service date, specialty, payer rule and reference versions the reviewer should use.
- Decide whether the denominator is encounters, code assignments or audited items. Document exclusions, incomplete records and the rule for counting multiple issues on one chart.
- Agree severity definitions and the rubric for modifiers, documentation gaps, overcoding, undercoding and unsupported changes before review begins.
Worked example
What does the coding lead receive?
Each finding identifies the encounter reference, original code or modifier, the questioned item, source evidence, rule version and status. For example, if a modifier lacks supporting documentation in the available chart, the reviewer records the missing support and sends it to the coding lead. The coding lead decides whether to query the provider, change the claim or retain the original coding.
- A finding register with reviewed item, error category, severity, rationale and status.
- A summary showing reviewed and excluded counts, the agreed scoring denominator and recurring causes.
- An action list for education or workflow correction, plus a repeat sample to check whether the issue persists.
Service detail / 04
Who makes the final decision?
Your coding lead resolves disputed findings and authorizes any code change, claim correction or provider query. Your clinician owns clinical interpretation and attestation. Agree who may access each system and where reviewers may work before records are shared. A scoped quality review does not establish independence for a statutory, payer or compliance audit.
- Request the proposed reviewer’s actual specialty experience and relevant current credentials before approval.
- Name who can approve access and verify any payer, contractual or geographic restrictions.
- Agree the escalation path when the reviewer and original coder differ. Keep both rationales and record the client’s disposition.
Service detail / 05
What determines the cost of a coding QA pilot?
Share the planned sample size, specialty, record complexity, code families and expected second-review rate. Ask for a scoped price with calibration, review, dispute handling and reporting shown separately. Compare cost per completed review using the same inclusion rules. Track time waiting for missing records independently from reviewer time.
- Pilot measures can include completed reviews, variance by severity, time per completed review, agreement after adjudication and issues recurring on recheck.
- Use a deidentified workflow summary for the first conversation. Do not paste patient identifiers or charts into the inquiry form.
- The scope must name the reviewer, decision owner, access conditions and acceptance criteria before any live record is released.
Before the first live queue
Bring the inputs that shape your scope
The proposal should identify what can be assigned, who can decide, and how you will accept the work. Start with one representative queue; agree any expansion after reviewing the pilot.
Define the workload
Specialty, encounter types, sample method and code-set version.
Agree the controls
Reviewer experience, access permissions and scoring rubric.
Review the right measures
Findings confirmed by your lead, corrections and repeat-error categories.
Before you decide
Buyer questions
Clarify the work, access and approval boundaries before assigning a team.
Can a billing company outsource a second review and keep sign-off?
Actigy BPO can prepare a separate review of a sample of completed charts. Agree the specialty, approved access and qualified reviewer first. Your coding lead resolves disagreements and approves corrections.
Can you measure coding accuracy from a sample of high-risk charts?
A targeted sample can reveal recurring issues in the selected charts. For an estimate of performance across a wider population, agree the sampling method, denominator, exclusions and review period in advance. Report targeted and baseline findings separately.
What happens when the second reviewer disagrees with the original coder?
Record the original rationale, reviewer finding, evidence and rule version, then send the dispute to your designated coding lead. The client authorizes any code correction. Clinical questions return to the provider and the final disposition stays in the review log.
Does this service replace an independent coding compliance audit?
This scope covers operational coding quality review. If a contract or authority requires an independent audit, your compliance owner must establish the required qualifications, independence and reporting terms before selecting an auditor.
What information is needed for a quote?
Send the intended sample size, specialty, payer mix, date range, code families, review deadline and permitted work locations. Share workload and access requirements only. Patient charts, identifiers and confidential payer contracts belong in a separately approved secure process.
Can you review completed coding before billing or after a claim was submitted?
The scope can identify either review point. For a pre-bill sample, name the person who can hold or release the claim. For a retrospective sample, agree how findings reach your coding lead and how any approved correction is recorded. Actigy BPO performs the agreed second review; your team decides whether to bill, query, amend or retain the original coding.
Discuss a coding review sample
Describe the specialty, approximate chart count and role that will approve corrections. Give the permitted reviewer locations. Do not send patient information.
Your inquiry
Medical coding audit support
Describe the workload and the decision owner. Keep confidential records out of the form; agree a suitable channel for any later sample.
- Review the fitWe review the workflow and the inputs you provide.
- Define the scopeDiscuss access, coverage, review and the proposed fee.
- Agree a paid pilotApprove the written scope before work begins.