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The three deficiencies cited most often in audit are: Counseling and anticipatory guidance recorded as a checkbox with no specificity in the note The physical examination section copied forward from the prior year's visit without any updates Preventive and problem-oriented components blended into a single narrative when both services were billed on the same date When an audit request or documentation denial arrives, submit the complete medical record for the date of service with a cover letter that identifies, section by section, where each required component is documented

Example A provider spends 15 minutes counseling a patient who smokes one pack per day about the health effects of tobacco use and the benefits of quitting

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Applying it to Medicare claims results in denial