A high-volume psychiatrist needed to know her coding was defensible.

The situation

She was a high-volume psychiatrist seeing 25 to 30 patients a day — a mix of medication management and therapy sessions — and billing 99214 and 99215 at rates well above the specialty average. She knew why: her patient population was complex, her sessions were longer than typical med checks, and she documented accordingly.

But Medicare doesn’t look at intent. It looks at patterns. A provider billing 99215 at twice the specialty rate shows up on a RAC contractor’s data mining report regardless of whether the documentation justifies it. She’d heard enough stories from colleagues who got audit letters out of nowhere — providers who were doing good work but couldn’t prove it on paper fast enough when the request came.

She didn’t have a compliance officer. She didn’t have a billing team. She had a part-time biller who processed claims and a SimplePractice account. If her coding was going to be defensible, she needed to know that now — not when an auditor told her it wasn’t.

What they needed

A way to validate every chart against Medicare documentation requirements before it became a claim. Not a quarterly review. Not a random sample. Every chart, checked the same way an auditor would check it — automatically, consistently, at the point of documentation.

It also had to be low-overhead. There was no compliance team to train, no workflows to redesign. It needed to work with SimplePractice and fit into the way she already documented.

How MedAudita fits

MedAudita pulls CCDAs from her SimplePractice account and runs each chart through 9 compliance checks. For a solo practice, the highest-value checks are the ones that validate whether the clinical narrative supports the E/M level billed. If she documents a 99215, the system checks that the note reflects the complexity, time, and medical decision-making that 99215 requires under current CMS guidelines.

Each chart gets a 4-tier risk score. A green chart means the documentation supports the code. An orange or red chart means there’s a gap — and she sees exactly what’s missing before the claim goes out. No guessing. No hoping the note was good enough.

The system also tracks her billing patterns over time. If her 99215 rate stays high, she has chart-level evidence that it’s clinically justified — not just a gut feeling, and not just the notes themselves, but a structured audit trail showing that every chart was reviewed and every code was validated. If a RAC review ever does come, the documentation is already organized for response.