What Should Be Included in a Medical Coding Audit Report?

A medical coding audit report should tell you more than your accuracy rate. The most useful reports show what was reviewed, where errors and trends are occurring, and how findings may affect reimbursement, compliance, and quality reporting. They also give coding leaders the information they need to target education, prioritize follow-up, and track improvement over time.

You finish a coding audit and get the results back: 95% accuracy.

That sounds good. But what does it actually tell you?

Were the errors concentrated in one area? Did any of the findings have a financial impact or make a difference in quality reporting? Were the same mistakes made over and over? And, maybe most importantly, is there anything your team needs to do differently because of what the audit found?

A medical coding audit report should help answer those questions.

Accuracy matters, but a useful audit report goes much further. It should show you what happened, where patterns are developing, why the findings matter, and where there may be an opportunity for education or additional review.

Here’s what you should expect to see.

Start With What Was Actually Audited

Before looking at an accuracy rate, you need some context.

What kind of audit was performed? How many records were reviewed? What time period did the audit cover? Were the records selected randomly, or was the audit focused on a particular coder, provider, DRG, APC, procedure, specialty, or known area of concern?

The report should clearly lay out the scope and methodology.

This matters because you can't look at the results of a 20-chart targeted review the same way you would look at a larger random audit of an entire coding department.

The numbers only mean something when you know what sits behind them.

Coding Accuracy — But Don't Stop There

Of course, the report should tell you how your team performed.

Overall coding accuracy provides a quick benchmark and makes it easier to compare results from one audit to the next.

But an accuracy percentage can also hide quite a bit.

Consider two coding teams that both finish an audit at 95% accuracy.

One team's findings are mostly isolated issues with little impact. The other team's findings include repeated coding errors with financial, compliance, or quality implications.

Same accuracy rate. Very different audit results.

That's why the percentage should be the beginning of the conversation, not the end of it.

The Actual Coding Findings

Next, you need to know what the auditor found.

Depending on the type of coding audit, that could include:

• Principal or primary diagnosis selection
• Secondary diagnoses that were missed or unsupported
• Procedure coding
• Sequencing
• DRG assignment
• APC assignment
• RVUs
• Payment indicators
• HCCs
• CCs/MCCs
• Modifiers
• Discharge disposition
• Point of Origin
• POA indicators
• Patient Safety Indicators (PSIs)
• Evaluation and management coding
• Documentation concerns

Not every one of these will apply to every audit. What matters is that the report captures the measures and findings that are relevant to the setting being reviewed, whether that's inpatient, outpatient, ASC, or professional fee coding.

Being able to see the individual findings is important, especially when coding managers or coders need to go back and understand what happened on a particular encounter.

But a long list of corrections isn't necessarily a useful report either.

The real value comes when you start looking at those findings together.

Look for the Patterns

This is where audit reporting gets interesting.

One incorrect code is a finding.

The same issue appearing on eight different encounters is a trend.

Maybe several coders are struggling with the same procedure. Maybe one DRG or APC keeps showing up in your findings. Maybe a particular provider's documentation is creating coding challenges. Or maybe an issue you thought was resolved during the last round of education is showing up again.

Those are the things you want your audit report to make easy to spot.

Look at findings by:

• Coder
• Provider
• Diagnosis
• Procedure
• DRG
• MDC
• APC
• Specialty
• Service line
• Type of error

You may find that what initially looked like several unrelated errors actually points to one larger issue.

And that gives you something you can act on.

Make Sure You Know Why a Change Was Recommended

There's a big difference between receiving feedback that says "change this code" and feedback that explains why the change is needed.

A strong audit report should give coders enough information to understand the auditor's recommendation.

When appropriate, that may mean referencing official coding guidelines, Coding Clinic, CPT guidance, payer guidance, or another applicable resource.

This is especially important when the goal is education.

If a coder understands why something was incorrect, there's a much better chance that knowledge carries over to the next chart. If they simply receive a corrected code, the same issue may show up again.

Don't Lose Sight of Financial Impact

Not every coding correction changes reimbursement.

But when it does, you should be able to see it.

The way financial impact shows up can also vary depending on the setting. For an inpatient audit, that may involve a change in DRG. In outpatient or ASC coding, an APC or payment indicator may be relevant. For professional fee coding, RVUs may help show the impact of a recommended change.

Audit reporting can help identify both sides of the equation: cases where coding resulted in an overpayment and cases where supported reimbursement may have been missed.

That distinction matters.

The goal of an audit isn't to find more money. It's to determine whether the coding accurately represents the documentation and services provided.

Still, understanding the financial impact of audit findings helps leaders see which issues deserve a closer look and where coding trends may be affecting revenue integrity.

Some Findings Matter Even When the Dollar Amount Is $0

This is an easy one to overlook.

A coding change may have no immediate reimbursement impact and still be important.

Could the change affect quality reporting? Does it impact a Patient Safety Indicator? Does it change an HCC, CC/MCC, severity measure, or another metric the organization monitors?

There are also compliance concerns that simply can't be measured by looking at dollars.

If the report only highlights findings that changed reimbursement, part of the story is missing.

Is It a Coder Issue or a Bigger Issue?

This is another question good audit reporting should help answer.

Suppose five coders make the same type of error.

That probably calls for a different response than one coder making the same error five times.

The first could point to a team-wide education need, a confusing guideline, or even an internal process that needs clarification.

The second may be better addressed through individual coaching and follow-up review.

The same goes for providers and service lines.

If documentation issues are consistently associated with a particular specialty or provider group, the answer may not be more coder education at all.

Being able to break audit results down into meaningful groups makes it much easier to figure out what should happen next.

The Report Should Tell You Where Education Is Needed

An audit shouldn't end when the report is delivered.

Ideally, the findings help shape your next round of education.

If one issue keeps appearing, that's a pretty good indication that it deserves attention. If the entire team is struggling with it, group education may make sense. If it's isolated, individual coaching may be enough.

Then comes the part that's easy to forget: check again.

Did the education work?

A follow-up audit can show whether the issue improved, stayed the same, or continued to appear.

That's how audit results become part of an ongoing quality process instead of a report that gets reviewed once and filed away.

Compare Today's Results With Yesterday's

A single audit tells you what happened in a group of records.

A series of audits can tell you whether you're getting better.

Being able to compare results over time helps answer questions like:

• Did accuracy improve?
• Did that recurring issue finally decrease?
• Are we seeing fewer findings in the area we targeted for education?
• Did something new start showing up?

Historical audit data can be incredibly valuable, especially when you're trying to determine whether changes in education, processes, or staffing are actually making a difference.

So, What Should a Medical Coding Audit Report Include?

At a minimum, you should be able to walk away from an audit report understanding:

• What was reviewed: The scope, sample, methodology, setting, and time period.
• How the coding performed: Overall accuracy and other performance measures relevant to the type of coding being audited.
• What was found: The specific coding recommendations and the rationale behind them.
• Where the patterns are: Recurring findings by coder, provider, diagnosis, procedure, DRG, MDC, APC, specialty, service line, or another relevant category.
• Why the findings matter: Financial, compliance, quality, or operational impact.
• What needs to happen next: Education, additional auditing, provider outreach, process changes, or other follow-up.
• Whether things are improving: Comparison with previous audits and trends over time.

If your audit report can't answer those questions, you're probably not getting everything you could out of your audit data.

Get More From Your Audit Data

A coding audit report shouldn't leave you with a percentage and more questions than you started with.

The most useful reports help you connect the individual findings to the bigger picture. They show you what's happening, where it's happening, why it matters, and what you may want to look at next.

That's also why having audit information in one place matters.

Atom Audit gives healthcare organizations a centralized way to manage coding audits, review findings, analyze trends, and track results over time. Instead of digging through spreadsheets or piecing together information from separate reports, teams can get a clearer view of what their audit data is actually telling them.

Because the real value of an audit isn't just knowing your accuracy rate.

It's knowing what to do with what you found.

Frequently Asked Questions About Medical Coding Audit Reports

What should be included in a medical coding audit report?

A medical coding audit report should include the audit scope and methodology, coding accuracy, individual findings, the rationale for recommended changes, trends, financial and quality impact, compliance concerns, education opportunities, and recommended next steps. When possible, it should also show how current results compare with previous audits.

Is coding accuracy enough to evaluate audit results?

No. An accuracy percentage is useful, but it doesn't show the type, severity, or impact of the errors identified. Looking at trends, financial impact, quality implications, compliance concerns, and repeat findings gives you a much better picture of coding performance.

What financial information should be included in a coding audit report?

The financial information will depend on the type of coding being reviewed. Depending on the setting, an audit may evaluate changes involving DRGs, APCs, payment indicators, RVUs, or other reimbursement-related measures. The goal is to show where coding findings may have affected reimbursement without treating financial impact as the only measure of audit importance.

Why should coding audit reports include quality measures?

Not every coding finding results in a change in reimbursement. Some findings may affect quality reporting, Patient Safety Indicators, HCCs, CCs/MCCs, severity measures, or other organizational metrics. Including these impacts provides a more complete picture of why a coding finding matters.

Why should coding audit reports include trends?

Trends help you determine whether you're looking at an isolated error or something bigger. If the same finding continues to appear across coders, providers, specialties, service lines, or audit periods, it may signal a need for education or additional review.

How can coding audit reports be used for education?

Audit findings can help pinpoint where coders or providers may need additional education. Future audits can then be used to see whether that education worked and whether the same findings continue to occur.

About Atom Audit

Atom Audit, powered by HIA— a leader in medical coding and auditing for over 30 years — combines user-friendliness with speed and intuitiveness in a coding review application. The platform features a customizable reporting dashboard designed to streamline the audit process from start to finish. Initially crafted and honed for over three decades to meet HIA's internal and client reporting needs, the platform's proven success and effectiveness led to its evolution into Atom Audit. This transition was driven by client demand, as they recognized the tool's value in enhancing their auditing processes and showed a keen interest in leveraging Atom Audit for their needs. Atom Audit distinguishes itself by enabling users to easily translate comprehensive audit findings into practical actions, thanks to its detailed and actionable insights. For more information, visit AtomAudit.com.