The world of medical billing and coding is not what it used to be—and that’s not necessarily a bad thing. As healthcare continues to evolve into a more digital, value-based, and patient-centric system, the role of coders and billers is more important—and more regulated—than ever.
If you’re a coder or biller, you’re not just crunching numbers or assigning codes. You’re the front line of compliance, revenue integrity, and operational excellence. But with increasing regulatory scrutiny, evolving payer rules, and complex coding updates, staying compliant in 2025 means staying informed, proactive, and prepared.
This comprehensive 2025 Compliance Checklist is designed to walk you through key areas you must be on top of to avoid penalties, audits, or revenue losses. Whether you’re in a hospital, physician practice, ASC, or revenue cycle management (RCM) firm—this guide is your go-to reference for staying compliant and confident this year.
1. Stay Updated with ICD-10, CPT, and HCPCS Code Changes
What’s New in 2025?
Each year brings significant updates to ICD-10, CPT, and HCPCS Level II codes. Missing a new or deleted code doesn’t just lead to denials—it could result in compliance violations.
Your 2025 Checklist:
- Review ICD-10-CM and ICD-10-PCS code updates (Effective Oct 1, 2024)
- Review CPT 2025 updates from AMA (Effective Jan 1, 2025)
- Review HCPCS 2025 quarterly changes (especially for Medicare Advantage)
- Remove deleted codes from your EHR and billing systems
- Re-train coding staff on high-impact changes
Pro Tip: Don’t just look at the codes—understand the documentation and medical necessity changes associated with them.
2. Master 2025 E/M Guidelines and Documentation Standards
Evaluation & Management (E/M) coding continues to evolve. If your team is still using outdated rules for time or MDM (Medical Decision Making), you’re risking non-compliant billing.
Your 2025 E/M To-Do:
- Adopt latest AMA guidance on split/shared services
- Implement time-based coding correctly across all specialties
- Ensure clinicians understand MDM criteria updates
- Validate proper use of telehealth E/M codes
- Audit random E/M charts monthly to ensure accuracy
Reminder: CMS continues to closely monitor high-level E/M codes (e.g., 99215, 99223) for upcoding. Regular self-audits help you stay compliant.
3. Tighten Up Your Telehealth Billing Practices
In 2025, telehealth is no longer “optional”—it’s a permanent fixture. But many organizations still struggle with telehealth billing compliance.
Telehealth Compliance Must-Haves:
- Verify the latest CMS telehealth covered services list
- Use POS 02 and POS 10 appropriately
- Document patient location and consent
- Watch out for audio-only billing errors
- Stay informed on commercial payer variations
Watch Out: Billing an in-person E/M code for a virtual visit is one of the most common compliance mistakes of 2024—don’t carry it into 2025.
4. Clean Up Modifier Usage
Incorrect modifier usage is one of the top triggers for 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)
Best Practice: Always review the operative report and encounter notes when applying modifiers to ensure clear justification.
5. Enforce Strong Internal Audit Protocols
You can’t fix what you don’t measure. Internal auditing is the cornerstone of proactive compliance.
Build Your 2025 Audit Plan:
- Quarterly audits of top 10 providers or high-volume coders
- Random sampling of charts across specialties
- Focused audits on known risk areas (e.g., high-level E/M, modifiers)
- Feedback loop with providers for education
- Track audit trends and act on findings
Goal: Create a culture where audits are a learning opportunity—not a punishment.
6. Prepare for the OIG & Payer Audits
The Office of Inspector General (OIG) has made it clear—2025 will bring intensified scrutiny on medical necessity, prior authorizations, and overpayments.
Stay Audit-Ready:
- Review the OIG 2025 Work Plan for your specialty
- Conduct mock audits with payer-specific focus
- Validate physician documentation supports billed services
- Keep appeal templates ready for common denials
Trending Alert: Medicare Advantage plans are increasingly targeted for overpayments and aggressive coding practices. Stay vigilant.
7. Ensure HIPAA and Data Privacy Compliance
HIPAA violations aren’t just about data breaches anymore—they include insecure remote access, unauthorized disclosures, and non-compliant texting between providers.
Protect Patient Data:
- Perform annual HIPAA Security Risk Assessment
- Update Business Associate Agreements (BAAs)
- Limit PHI access based on user roles
- Encrypt all remote workstations and mobile devices
- Train staff on phishing and ransomware threats
Remember: Compliance isn’t just about codes—it’s about trust and confidentiality.
8. Standardize Denial Management and Appeals
Compliance doesn’t end at claim submission. Denied claims—especially those repeatedly denied—can indicate compliance red flags.
Build a Strong Denials Strategy:
- Categorize denials by type (coding, documentation, auth)
- Analyze root causes monthly
- Set internal benchmarks for timely appeals
- Document and track appeal outcomes
- Use AI tools for smart denial predictions (where available)
Pro Tip: Train coders to flag problematic trends BEFORE denials happen. Prevention beats correction.
9. Conduct Annual Compliance Training & CEUs
If your team hasn’t had formal compliance training this year—you’re already behind.
For 2025:
- Provide mandatory annual compliance training (with logs)
- Ensure coders and billers maintain AHIMA, AAPC, or specialty-specific certifications
- Offer monthly refreshers on coding updates
- Include real-case examples and scenarios
- Document all training sessions and attendee lists
Suggestion: Mix up your training methods—try webinars, case reviews, and compliance quizzes to keep it engaging.
10. Embrace Technology with Compliance in Mind
From AI-assisted coding to robotic process automation (RPA), technology is everywhere—but it must be implemented with governance and validation.
Tech Use Compliance Checklist:
- Validate coding suggestions from AI tools
- Limit bot access to PHI and audit logs
- Secure API integrations with EHRs
- Monitor AI for upcoding risks or false recommendations
- Stay informed on emerging AI compliance guidelines
Reality Check: Tech doesn’t replace human coders—it enhances them. But you are still responsible for what gets billed.
11. Address Social Determinants of Health (SDOH) Coding
Payers are watching how practices handle health equity. The new Z codes and SDOH reporting will influence reimbursement and compliance audits.
Don’t Miss These Steps:
- Incorporate Z codes into patient intake and documentation
- Train providers to document housing, food insecurity, transportation issues
- Code relevant SDOH using ICD-10-CM Z55–Z65
- Track trends to address population health needs
Bottom Line: Compliance now includes whole-person care—not just clinical care.
12. Revisit Your Compliance Plan Annually
Your Corporate Compliance Plan isn’t a document you create once and forget. It should evolve with the regulations, workforce, and technology.
Review Your 2025 Compliance Plan:
- Designate a compliance officer or manager
- Update based on OIG, CMS, payer guidance
- Include response protocols for breaches and violations
- Align policies with HR, IT, and legal departments
- Share plan highlights with staff regularly
Need a Template? Start with OIG’s 7 Elements of an Effective Compliance Program.
Compliance is a Journey, Not a Checkbox
2025 isn’t the year to “wait and see.” With audits increasing, technology advancing, and payer rules changing rapidly, proactive compliance is your competitive advantage.
If you’ve read this far—great job. You clearly care about doing things right.
But don’t keep this knowledge to yourself. Share this checklist with your team. Create a discussion. Schedule a meeting. Start an audit. Update a process. Compliance isn’t a one-person job—it’s a culture you build together.