HOW BIS REDUCED CODING ERRORS THROUGH TARGETED PROVIDER EDUCATION
Business Integrity Services (BIS) partnered with one of the largest multi-specialty medical groups in the country, operating across three states, to address recurring issues with provider selection of code for service. BIS has assigned certified coders to handle the organization’s billing, based on coding guidelines and supporting documentation.
In order to improve provider selection of both lower and higher code, BIS’s coding leadership team launched monthly educational sessions in February 2025, attended by 39 clinical providers from the organization. These sessions, held in a presentation-style format lasting 30 minutes, were designed to improve documentation standards and increase provider awareness of accurate code selection based on medical documentation.UPCODING
Upcoding involves billing for a higher level of service than was actually provided. This can trigger compliance flags, legal consequences, and damage trust with payers and patients.
Upcoding typically occurs when a healthcare provider, or billing staff assigns a code that makes a service appear more complex or expensive than it actually was. Upcoding often happens by mistake. Common reasons include unclear or incomplete documentation that makes it hard for coders to choose the correct code, confusion about coding guidelines, or relying too much on electronic health record (EHR) systems that autoselect higher-level codes. Providers may also use templated notes that make routine visits seem more complex than they are. These issues are especially common in busy clinics where coders or providers haven’t received consistent education or feedback on proper documentation and coding practices.
DOWNCODING
occurs when providers bill for a lower level of service than appropriate. This leads to significant revenue leakage and underrepresents the complexity ofcare delivered. In most cases, downcoding is unintentional. It often happens when providers under-document key elements of the visit, making it difficult for coders to justify a higher-level code. Sometimes, providers may downcode out of caution – fearing audits or penalties or because they’re unsure of documentation requirements. Lack of training on Evaluation and Management (E/M) coding guidelines and inconsistent feedback can also contribute. Over time, routine undercoding not only impacts revenue but can also create inaccurate patient records and skew performance data used for clinical or financial decision-making.
Since the launch of these sessions in February 2025, the large multi-specialty medical group has seen consistent,
measurable improvements in provider code selection. Selection of lower and higher code trends have declined steadily
– a clear indicator that BIS’s monthly education has helped providers better understand how to document services
accurately and code in alignment with clinical complexity and payer expectations.
OVERALL TREND
Provider selection of a lower and higher
code declined steadily month over
month, reflecting a consistent
improvement in provider’s selection of the
appropriate code and compliance. This
trend suggests a strong adoption of
education efforts across the provider base
Location: Chennai, India
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