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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

Human Subjects Statement The studies were approved by the Penn State Hershey, George Washington University, and Partners Human Research Committee (Massachusetts General Hospital) Institutional Review Boards

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