Every compliance program audits for overcoding. Almost nobody audits for the opposite – and in internal medicine, undercoding is usually the larger number.

How Undercoding Happens

Physicians who lived through payer audits learned to default to 99213. Since the 2021 E/M revisions, medical decision making or total time alone supports the level, and a visit addressing two chronic conditions with prescription management legitimately meets 99214. The habit persists anyway, and the payer happily pays the lower code forever. No denial. No signal. No correction.

The Physician Distribution Report

Run each physician E/M distribution – the percentage of 99212 through 99215 – side by side against specialty benchmarks. Every internal medicine group that runs this for the first time finds two or three clinicians sitting far left of peers with identical panels. The fix is education and a documentation prompt, not pressure: permission to code what the note already supports.

Payer Downcoding: The New Failure Mode

The mirror image now runs on the payer side. Several national commercial payers algorithmically reprice high-level E/M downward at adjudication – paid below the billed level, often without a clear remark code. Detection requires comparing billed level to paid level, line by line, by payer. These overturn at high rates on appeal, but only if someone notices.

Modifier 25 Reductions

Same-day E/M with a minor procedure used to deny; on a growing number of plans it now pays at 50-75% of allowable instead. Reductions never enter a work queue. Compare paid amounts on modifier-25 E/M lines against the same codes without a same-day procedure, split by payer. A consistent gap on one payer is a policy, and a policy can be fought once rather than claim by claim.

The Honest Top-Line Metric

Denial rate and clean-claim rate can both look excellent while undercoding, downcoding and reductions run. Paid dollars per work RVU, by payer, trended over 24 months, is the metric that cannot be flattered – the denominator is the work the physicians actually performed.

Revenant Care runs billing operations for physician groups. Every report specification in this guide is available via our contact page – usable with or without us.