Solution: Undercoding Revenue Loss
Undercoding never shows up as a denial. It never generates an alert. It just quietly reduces your reimbursement, quarter after quarter, while your biller files clean claims for the wrong amount. Specialty practices lose revenue to undercoding every year, without knowing it.
Root Causes
Undercoding is almost always systematic, the same error made on the same type of visit or procedure, month after month. Here are the most common patterns we find.
Providers or billers consistently select 99213 when the documentation supports 99214, or 99214 when it supports 99215. A single E/M level difference is $40.42 per visit at 2026 Medicare rates (99213 vs 99214).
Add-on codes (like 90833 for psychiatric medication + therapy, or 99292 for additional critical care time) are frequently omitted because they require an extra billing action. Each missed add-on is missed revenue.
In-office procedures, education sessions, care coordination time (99490/99491 for CCM), and remote patient monitoring (99457/99458) are frequently rendered but never billed.
Missing modifier 50 (bilateral), modifier 22 (increased procedural complexity), or modifier 52/53 (reduced/discontinued service) can mean under-reimbursement of 20–50% on affected procedures.
In GI and oncology, when a procedure converts from screening to diagnostic (e.g., colonoscopy with polyp removal), the CPT code and billing must change. Missing this single conversion costs GI practices $19,000+/month.
When a physician and APP both contribute to a visit, billing under the APP's NPI instead of the physician's can reduce reimbursement by 15% (Medicare pays 85% of the physician rate for APP-billed services).
Our Approach
We pull 90 days of your submitted claims and compare coded level to documentation complexity. Every E/M code is reviewed against the documented MDM or time. Every procedure is checked for missing add-ons and modifiers.
The audit produces a specific dollar figure: how much additional revenue your existing patient volume supports if billed correctly. Not a range: a specific number based on your actual claims data.
We identify which providers are undercoding (often out of compliance caution) and which procedures are systematically under-billed. This gives you a targeted education focus.
For correctable past claims within timely filing windows, we submit corrected claims. For future claims, we implement coding QA checkpoints that catch under-coded visits before submission.
Undercoding drifts back over time without ongoing monitoring. We conduct quarterly coding audits for all clients, comparing reimbursement per encounter trends to catch early regression.
Illustrative Scenarios
Our free revenue assessment includes a coding audit that identifies your specific undercoding pattern and puts a dollar figure on the gap, within one week of access to your claims data.