2025 Medical Billing & Coding Compliance Checklist

By Author: Albert
Total Articles: 90
Comment this article

The field of medical billing and coding is constantly changing, and that's a good thing. With the healthcare industry becoming more digital, patient-focused, and value-based, the work of billers and coders is more important than ever. You're not just processing numbers and assigning codes; you are the first line of defense for compliance, revenue integrity, and operational excellence.
However, with increased regulatory oversight, complex payer rules, and frequent coding updates, staying compliant in 2025 means being proactive and prepared. This checklist is your guide to navigating these challenges and ensuring your revenue cycle management (RCM) is strong. It's designed to help you avoid penalties, audits, and revenue losses, whether you're in a hospital, physician practice, or an RCM firm.
12-Point 2025 Compliance Checklist for Medical Billing & Coding
1. Stay on Top of Coding Updates
Each year, there are significant changes to ICD-10, CPT, and HCPCS Level II codes. Failing to use the most current codes can lead to claim denials and compliance violations.
Your 2025 Checklist:
Review ...
... ICD-10-CM and ICD-10-PCS code updates (effective October 1, 2024).
Review CPT 2025 updates from the AMA (effective January 1, 2025).
Review quarterly HCPCS 2025 changes, especially for Medicare Advantage.
Update your EHR and billing systems to remove any deleted codes.
Train your coding staff on high-impact changes.
Pro Tip: Don't just focus on the codes themselves. It's crucial to understand the documentation and medical necessity changes that go with them.
2. Master 2025 E/M Guidelines
Evaluation and Management (E/M) coding continues to evolve. If your team is still using outdated rules, you're at risk for non-compliant billing.
Your E/M To-Do List:
Adopt the latest AMA guidance for split/shared services.
Correctly implement time-based coding across all specialties.
Ensure clinicians understand the updated Medical Decision Making (MDM) criteria.
Validate the proper use of telehealth E/M codes.
Conduct monthly audits of random E/M charts to ensure accuracy.
3. Tighten Up Telehealth Billing Practices
Telehealth is a permanent part of healthcare, but many organizations still struggle with its billing compliance.
Telehealth Must-Haves:
Verify the latest CMS list of covered telehealth services.
Use Place of Service (POS) codes 02 and 10 correctly.
Document the patient's location and consent.
Watch out for errors in billing for audio-only visits.
Stay informed about variations in commercial payer rules.
4. Clean Up Modifier Usage
Incorrect use of modifiers is a common cause of audits and denials.
2025 Modifier Watchlist:
Modifier 25: Significant, separately identifiable E/M.
Modifier 59: Distinct procedural service.
Modifier 95: Telehealth services.
Modifier FT: Unrelated E/M visit during a post-op period.
Modifier JW & JZ: Drug wastage reporting.
5. Enforce Strong Internal Audits
You can't fix what you don't measure. Internal auditing is key to proactive compliance.
Build Your 2025 Audit Plan:
Conduct quarterly audits of your top 10 providers or high-volume coders.
Sample charts randomly across different specialties.
Focus audits on known risk areas like high-level E/M codes and modifiers.
Provide educational feedback to providers based on audit findings.
Act on any trends identified during audits.
6. Prepare for Audits by the OIG and Payers
The Office of Inspector General (OIG) has made it clear that 2025 will bring increased scrutiny of medical necessity, prior authorizations, and overpayments. Being audit-ready is essential for all RCM services.
Stay Audit-Ready:
Review the OIG 2025 Work Plan for your specialty.
Conduct mock audits with a focus on specific payers.
Ensure physician documentation supports billed services.
Have appeal templates ready for common denials.
7. Ensure HIPAA and Data Privacy Compliance
HIPAA violations go beyond data breaches. They also include insecure remote access, unauthorized disclosures, and improper communication between providers.
Protect Patient Data:
Perform an annual HIPAA Security Risk Assessment.
Update your Business Associate Agreements (BAAs).
Limit access to protected health information (PHI) based on user roles.
Train your staff on how to spot phishing and ransomware threats.
8. Standardize Your Denial Management
Compliance doesn’t end with claim submission. Denial management is critical because repeatedly denied claims can be a red flag.
Build a Strong Denials Strategy:
Categorize denials by type (e.g., coding, documentation, authorization).
Analyze the root causes on a monthly basis.
Set internal goals for timely appeals.
Track the outcomes of your appeals.
9. Conduct Annual Compliance Training
If your team hasn’t had formal compliance training this year, you're already behind.
For 2025:
Provide mandatory annual compliance training and log attendance.
Ensure your coders and billers maintain their certifications.
Offer monthly refreshers on new coding updates.
Include real-life case examples and scenarios in your training.
10. Embrace Technology with Compliance in Mind
Technology like AI-assisted coding is everywhere, but it must be implemented carefully and validated.
Tech Compliance Checklist:
Validate any coding suggestions from AI tools.
Limit bot access to PHI and audit their logs.
Secure all API integrations with your EHR.
Monitor AI for potential upcoding risks or false recommendations.
11. Address Social Determinants of Health (SDOH)
Payers are paying close attention to how healthcare providers address health equity. The new Z codes for SDOH will impact reimbursement and compliance audits.
Key Steps:
Incorporate Z codes into patient intake and documentation.
Train providers to document issues like housing, food insecurity, and transportation.
Track trends in SDOH to help address population health needs.
12. Revisit Your Compliance Plan Annually
Your Corporate Compliance Plan is a living document that should evolve with new regulations, workforce changes, and technology.
Review Your 2025 Plan:
Designate a compliance officer or manager.
Update the plan based on the latest guidance from the OIG and CMS.
Include clear protocols for responding to breaches and violations.
Share highlights of the plan with your staff regularly.
Compliance Is a Journey, Not a Checkbox
2025 is not the year to "wait and see." With audits increasing and regulations changing, proactive medical billing services are your best competitive advantage. Share this checklist with your team, start a discussion, and update your processes. Compliance is a team effort.

Read more: https://www.allzonems.com/medical-billing-coding-compliance-checklist/