In RHCs and FQHCs, compliance risk often doesn’t come from blatant errors—it comes from small documentation gaps that accumulate across encounters.
What Encounter Integrity Really Means
An encounter is more than a scheduled visit. From a compliance standpoint, documentation must clearly establish:
- Who provided the service
- What services were performed
- Why the service was medically necessary
- That the visit qualifies under program rules
If documentation does not clearly support these elements, the encounter itself becomes vulnerable—even if the care provided was appropriate.
Coding Accuracy Is a Compliance Issue, Not Just a Revenue Issue
Coding errors are often framed as financial problems, but they are also compliance concerns. Inaccurate coding can lead to:
- Incorrect encounter reporting
- Over- or under-billing
- Misalignment between documentation and claims
Over time, these inconsistencies create patterns that are visible in audits and data reviews.
The Compounding Effect of Small Errors
One incorrectly documented visit may not trigger concern. But when similar issues appear repeatedly—such as vague problem lists, unsupported diagnoses, or inconsistent E/M selection—they signal systemic risk.
This is where proactive audits become essential:
- They identify patterns early
- They allow clinics to course-correct internally
- They reduce exposure before external review
Why this matters:
Encounter integrity is the foundation of compliance, reimbursement, and trust. Documentation and coding audits protect that foundation.
How can we help?
We have audits designed to align with compliance monitoring that does not require additional staffing in your clinic.
With our RapidCheck audit, we can provide:
- A small, targeted sample of records
- Focused on documentation, coding, and encounter integrity
- Data-driven findings clinics can act on immediately
- Results in as little as 30 days for under $300 per clinician
It’s not a replacement for a full audit—it’s a practical compliance checkpoint that helps clinics stay ahead of issues before they become problems.
Compliance doesn’t have to be reactive or overwhelming. With the right focus and the right tools, clinics can maintain documentation and coding integrity while supporting sustainable operations without adding staff.
If your clinic is looking for a right-sized, documentation-focused compliance review, BCA may be a practical place to start. Contact us at info@bcarev.com to schedule some time to discuss, or learn more about our RapidCheck audits here: https://www.bcarev.com/rapidcheck-audit/