Medical Billing Compliance Checklist
37 audit items across nine risk areas: medical necessity, modifiers 25 and 59, incident-to, E/M leveling, ABNs, the 60-day overpayment rule, OIG exclusion screening, records retention, and telehealth. Each item has a cite and a plain-language way to check it. Score your practice, then print the report.
Click an item to mark it met. Use N/A for items that do not apply.
0%
0 of 37 scoreable items met
Medical Necessity Documentation
0/4 met
Every Medicare denial and most recoupments trace back to SSA §1862(a)(1)(A): the service must be reasonable and necessary, and the chart has to prove it.
Modifier 25 and 59 Use
0/4 met
Modifiers 25 and 59 override payer edits. OIG audits target both because they are the easiest way to unbundle services that should be paid once.
Incident-To Billing
0/4 met
Billing an NP or PA visit under the physician's NPI pays 100 percent instead of 85 percent. Every condition in 42 CFR 410.26 must be met or the 15 percent difference is an overpayment.
E/M Level Support
0/4 met
Since 2021 office visits, and since 2023 hospital and nursing facility visits, are leveled by medical decision making or total time. Level 4 and 5 visits without MDM support are the top recoupment target.
ABN Issuance
0/4 met
Without a valid Advance Beneficiary Notice you cannot bill the patient for a Medicare-denied service. With an invalid one, you have a patient billing complaint.
Credit Balances and Refunds
0/5 met
Keeping an identified overpayment more than 60 days converts a billing error into a False Claims Act liability with per-claim penalties and treble damages.
OIG Exclusion Screening
0/4 met
Federal programs pay nothing for items or services furnished, ordered, or prescribed by an excluded person. Employing one exposes every affected claim to civil monetary penalties.
Records Retention
0/4 met
A claim you cannot support with a record is treated as unsupported. Retention failures can also lead to Medicare enrollment revocation.
Telehealth Billing
0/4 met
Medicare telehealth flexibilities are statutory and temporary. They currently run through December 31, 2027; billing on an expired flexibility is an overpayment.
FIG · 01What Is a Medical Billing Compliance Checklist?
A medical billing compliance checklist is a self-audit that tests whether the claims a practice submits can survive a payer review. It sits alongside, not inside, your HIPAA compliance checklist: HIPAA governs how you handle patient information; billing compliance governs whether you were paid correctly for the care you documented.
This version has 37 items across nine risk areas that come straight from the OIG Work Plan, MAC audit programs, and the False Claims Act settlements that make the news. Every item cites the rule it comes from and tells you exactly what to pull to prove it. It pairs with the compliance work plan and the HIPAA audit checklist for a full annual program.
How to Use This Checklist
- 1
Start with the four high-risk coding areas
Medical necessity, modifiers, incident-to, and E/M leveling are where MACs and the OIG extrapolate. Pull 10 claims per provider and grade them against the "how to check" line on each item.
- 2
Mark items met, gap, or N/A
Click an item to mark it met. Use N/A for items that genuinely do not apply (the CMS-838 report for a physician practice, for example). N/A items are removed from the score so it stays honest.
- 3
Read the Fix First line
Any area under 70 percent shows up in the score panel. Those are the areas to open a corrective action for, using the work plan template to assign an owner and a date.
- 4
Print or copy the report for the compliance file
OIG expects evidence that auditing happened. Keep the dated report with your compliance committee minutes.
Billing Compliance Deadlines at a Glance
These are the clocks that matter most in a billing audit. Put each one on the compliance calendar with a named owner.
| Trigger | Deadline | Authority |
|---|---|---|
| Overpayment identified | 60 days to report and return | 42 CFR 401.305(b) |
| Related-overpayment investigation | 180 days max, then the 60-day clock runs | 42 CFR 401.305(b)(3) |
| Overpayment lookback | 6 years from receipt | 42 CFR 401.305(f) |
| Medicare claim filing | 12 months from date of service | 42 CFR 424.44 |
| Exclusion screening | Monthly (LEIE, SAM, state lists) | OIG SAB, May 2013 |
| Medicare order/referral records | 7 years from date of service | 42 CFR 424.516(f) |
| HIPAA compliance documents | 6 years | 45 CFR 164.530(j) |
| Part A credit balance report | 30 days after each quarter | Form CMS-838 |
| Medicare telehealth flexibilities | Expire Dec 31, 2027 unless extended | CAA, 2026 |
| Revised ABN form mandatory | May 12, 2026 (valid to Mar 31, 2029) | CMS-R-131 |
Example: A Three-Physician Family Practice
A practice with three physicians and two nurse practitioners runs the checklist for the first time. The coding areas score well, but two findings stand out.
Incident-to: one NP has been the only clinician seeing 40 established patients for 18 months, all billed under a physician's NPI. The chart shows no physician visits in that period. The practice re-bills the last six years of those visits under the NP's NPI and refunds the 15 percent difference within 60 days of finishing the review.
ABN: the intake template still prints the ABN version that expired in January 2026. Any ABN signed on that form after May 12, 2026 is at risk, so the template is swapped and the front desk is retrained the same week.
Both findings go on the work plan. Neither is a fraud case, but both would have been if they had been found by a payer first. The Stark and Anti-Kickback guide covers the referral-side risks this checklist does not.
Common Questions
Cites verified against the eCFR, CMS manuals, and OIG guidance as of August 2026. This is general compliance information, not legal advice. Confirm current rules with your MAC and counsel before acting on a finding. Related reading: ABN guide, clinical documentation improvement, common HIPAA violations.
Related Tools & Guides
Advance Beneficiary Notice Guide
When an ABN is required, how to fill it in, and which modifier to append.
Stark Law vs. Anti-Kickback Statute
The referral-side rules that billing compliance audits do not cover.
Compliance Work Plan Template
Turn checklist gaps into owned, dated corrective actions.
Clinical Documentation Improvement
How to get notes that support the E/M level and the diagnosis codes.
HIPAA Compliance Checklist
The privacy and security side of the compliance program.
Compliance Operations Hub
All tools and guides for running a practice compliance program.