Many readers of this site optimize their retirement and savings accounts, disdaining 1% expense ratios and working diligently to ensure that their money works for them. However, many of the same medical professionals may be leaving 10%, 20%, or more of their reimbursement behind every year, due to complex and confusing coding rules.
I know because for years I was one of these people. I am an orthopedic sports medicine surgeon, and in 2023, I was surprised to see that I had not hit a relative value unit (RVU) production bonus, despite being the busiest surgeon in my department that year. The hospital told me that the numbers were correct on its end, but it still didn’t seem right to me. So, I kept a running count of every coded interaction for six months in 2024—every surgery, every patient seen in clinic, every cast placed, and every consult in the hospital. When I compared it against the hospital number, I realized that I was only receiving approximately 80% of the credit for the work that I was doing.
Looking into this carefully, I saw that I was frequently being downcoded because of small documentation gaps. For example, I would discuss smoking cessation with a patient, document it, and code it. But I was not including the exact number of minutes that I spent discussing tobacco cessation, and thus, it was not receiving the code and the RVUs for this work.
Once I realized what was happening, I worked hard to improve my situation. I read the rules, documented carefully, and saw my RVU number improve to where it should have been. I then started working with colleagues, who almost always were falling into the same traps that I had. I’ve now helped many colleagues, and I am happy to report that almost all of them have shown improvement in their coding compliance and their RVU earnings.
One important point to stress: I want to help others code correctly. Not higher and not lower, but correctly. We do hard work and deserve the credit for the work that we do. Overcoding is illegal and immoral. The goal is accuracy.
Why Is There a Gap in What We Do and What We Code?
Most of us were never formally taught to code. I spent 10 years in training as a medical student, resident, and fellow, and I cannot remember a single education session on coding. For many of us, our contracts, bonuses, and departmental funding depend on our coding. Additionally, the rules changed with a major overhaul of the coding system in 2021 and 2023—when evaluation and management (E/M) visits became based on time or medical decision-making (MDM) rather than the number of bullet points on the history and physical exam.
The coders that I know are intelligent and want the providers they work with to get the appropriate credit for the hard work they do. However, they can only spend a few minutes on each note, and they can only code based on what is documented in the note. It behooves us as providers to make their job easy, as we are the only people who know what work was done in the exam room.
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What Can I Do to Code More Correctly?
You can audit your work. Find out who your coder is and speak with them. Most hospitals are happy to audit your recent work. Look to see if the coder agreed with what you coded. Then see whether what you coded appropriately matches the complexity of the visit. If there are errors, try to understand why they occurred and prevent these from happening in the future.
What Are Common Mistakes in Coding?
- Reflexively coding a Level 3 visit for all patients. I know many providers who do this. Some have slightly more complex rules—a Level 4 for new patients and a Level 3 for established patients. This is not the correct way to code. A Level 4 visit is described as moderate MDM and requires at least moderate decision-making in at least 2 of 3 areas: problem, data, and risk. Two chronic illnesses addressed in one visit gives credit for moderate MDM, as does prescription drug management. So, if you treat an established patient with diabetes and obesity and manage diabetic medications, you are performing a Level 4 visit. Make this clear in your note and discuss the medication change (name, dose, route, and frequency), and you should receive the correct credit.
- Long visits may code to higher levels than MDM allows. For example, I occasionally have a patient feel faint in my office while undergoing an exam. I recline the table, have the nurse in clinic join us, obtain vital signs, and stay with the patient until they feel better. If I spend 42 minutes with an established patient, regardless of the MDM complexity, I know that I can appropriately code an established Level 5 visit. I document the exact time in minutes I spent on the care of the patient on the day of service, including reviewing the chart, history, exam, direct care, and note writing. I use a macro phrase, which is prewritten and includes these points.
- Caring for patients where you manage longitudinal, ongoing responsibility. The relatively new code G2211 can be applied in these situations (although not when coding a consult or when you also submit a same-day minor procedure). This code is meant to credit providers for the complexities of managing long-term patients with chronic conditions. The 0.33 RVU per visit may seem small, but if you perform this work for 10 patients a day five days a week, that’s an extra 750 RVUs per year.
- Missing out on tobacco cessation counseling. I firmly believe that counseling my patients against smoking not only improves the success rates of surgeries that I perform, but it also may be more beneficial to their general health than anything that I can do in the operating room. I try to address smoking in all patients that I see. If I spend more than three minutes discussing tobacco use, recommending quitting, and discussing tools to help them, which happens with many of my patients, I will then code 99406 (4-10 minutes) or 99407 (>10 minutes).
What Happened When I Fixed My Coding?
I learned the rules from a variety of sources, connected with my coders, and started tracking my coding and expected RVUs. I saw my productivity rise to the level that I had predicted it should be.
Much like compound interest, even small changes can add up over time—750 RVUs a year, if paid at $45 per RVU, is more than $33,000.
Pull some notes this week. Look over your numbers. Do the math yourself. The hard and important work is already being done. It just needs to count.
How closely do you look at your coding? Is there room for improvement? What else can you do to make more money?
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