Article Reference Code: NAMAS.09.05.2025
Redefining Optimization: When Compliance and Reimbursement Work Together
Written by: Shannon DeConda
Not long ago, phrases like “optimize your coding” or “optimize your reimbursement” were standard language in consulting, auditing, and coding departments. They were on the front page of slide decks, on conference banners, and in strategy meetings with leadership. And they made sense, we were hired to help organizations capture accurate revenue and streamline processes.
But in today’s compliance environment, those same phrases raise eyebrows. In fact, many professionals hesitate to say them out loud, as though the words themselves imply some intent to deceive or manipulate the system. Somewhere along the way, the word “optimize” got a bad rap.
So let’s clear the air.
Optimization is not fraud. Misrepresentation is.
And yes, an audit and coding department still plays a central role in optimizing both coding and reimbursement. The difference is in how we do it, why we do it, and what principles guide the process.
The Shift in Language
Over the past 10–15 years, we’ve watched a growing sensitivity around language that suggests financial intent. Consultants have silenced from saying “revenue optimization,” even though that’s exactly what we do, so long as it’s done compliantly. “Coding optimization” has been replaced with phrases like “documentation alignment” or “accurate code selection based on medical necessity.”
Those phrases are fine, and they reflect a matured industry. But we shouldn’t lose sight of the fact that when documentation is thorough, coding is accurate, and compliance is front and center, reimbursement improves. That’s not manipulation. That’s operational success!!
What’s become taboo isn’t the goal, it’s the shortcuts some have taken in pursuit of that goal. Upcoding. Unbundling. Inflating time. Assigning diagnoses without proper linkage. These are not optimization strategies. They’re risk exposures. And in some cases, they’re fraud.
But that’s not what reputable coding and auditing teams do.
Reclaiming the Intent of Optimization
When we talk about optimization today, we’re not talking about pushing boundaries or inflating codes. True optimization in an audit or compliance program is about making sure providers are fully capturing the services they’ve already performed, with documentation that supports the story of the encounter. It’s recognizing when something important is missing from the note, such as elements that demonstrate medical decision making or clarify patient risk, and guiding providers on how to document that appropriately.
It’s also about connecting the dots for physicians, helping them see how clinical care and compliant code selection intersect. Optimization happens when auditors and educators don’t stop at pointing out errors, but also highlight opportunities to strengthen documentation and ensure the work performed is fully reflected. And on an organizational level, it means partnering with revenue cycle teams to identify where systemic issues are causing underreporting or unnecessary downcoding. In every case, the focus is on validation, not inflation, on making sure what’s done is documented, and what’s documented is reported. That’s where compliance and reimbursement goals align.
What the Guidance Actually Says
Neither AMA nor CMS has ever said that optimization is off-limits. Their message has been consistent: report what you do, and do what you report. For example, CPT guidelines are clear that a problem is only considered addressed if it is actually evaluated or treated by the reporting provider. CMS expects coding to reflect what’s documented, what is medically necessary, and what is connected directly to the services rendered. Medical decision making must be grounded in documented problems, data reviewed, and the risk of the management decisions made.
That said, it’s important to recognize how wording around “optimization” can be scrutinized. Members of our own team who have served as expert witnesses have seen phrases pulled from articles, presentations, or websites and used to suggest intent to encourage upcoding, even when that was never the case. The reality is that AMA and CMS guidance makes it clear this is not about over-coding or under-coding. It is about correct coding.
What they prohibit isn’t optimization, it’s misrepresentation. Unsupported diagnoses, levels of service that outpace documentation, or coding that stretches beyond medical necessity all cross the line into compliance violations. That’s not optimization. That’s risk. True optimization lives within the guardrails these guidelines set, ensuring that coding reflects the full scope of the encounter and that reimbursement is both appropriate and defensible.
The New Language of Optimization
So, how do we talk about this work without triggering red flags or raising questions? Here’s how we’re framing it now, and how you can confidently talk to leadership, providers, and compliance officers:
Instead of:
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“Optimize your coding”
Try: “Ensure your coding reflects the full scope of care delivered”
Instead of:
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“Maximize your reimbursement”
Try: “Support appropriate reimbursement through defensible, policy-aligned documentation”
Instead of:
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“Capture more revenue”
Try: “Improve documentation accuracy to prevent missed billing opportunities and denials”
It’s not just about semantics, it’s about trust. The language we use should reflect our purpose, which is to be good stewards of both compliance and financial integrity.
The words may have changed, but the mission hasn’t. We’re here to help organizations accurately reflect the care delivered, remain compliant with evolving regulations, and support the financial sustainability of the practices we serve.
Optimization isn’t the problem. It’s the standard. So long as it’s built on the foundation of compliance, transparency, and clinical integrity, we don’t need to tiptoe around it.
We just need to do it right—and say it right.
Shannon O. DeConda, CPC, CPMA, CEMA, CEMC, CPA-EDU
As Founder and President of NAMAS, and VP of Regulatory Compliance at DoctorsManagement, I’ve spent over 20 years equipping auditors, coders, and compliance professionals to lead with confidence—through rigorous education, practical mentorship, and a commitment to raising the bar for compliance excellence.
