The situation
Repair complexity and additional Mohs stages were not consistently captured from operative documentation.
Pathology and office-visit combinations generated modifier errors and preventable payer requests for records.
What we did
- 01
We audited charts by provider and procedure family, then quantified undercoding and compliance exposure separately.
- 02
Coder guidance linked each correction to the operative note elements required to support it.
- 03
Templates and pre-bill edits were updated so missed stages, repairs and modifier combinations surfaced before submission.
The result
- — The audit identified a $286K annualized revenue opportunity from work already documented.
- — Coding accuracy reached 98.8% on follow-up sampling.
- — Modifier-related denials and records requests fell 67% in four months.
"The audit was practical: every finding showed the chart, the code, the dollar impact and the exact correction."