Under-coding and Missed Charge Capture in E/M Coding
Definition
Physicians often under-code E/M services (e.g., defaulting to 99213 instead of higher levels) due to audit fears or incomplete documentation, missing higher reimbursements. Charge capture failures occur when services like SDOH screenings are not billed despite documentation. This leads to systemic unbilled services and underpayments in clinical documentation workflows.
Key Findings
- Financial Impact: $10M+ annually for mid-sized groups; 1-2% net revenue loss
- Frequency: Daily
- Root Cause: Inadequate documentation supporting higher E/M levels, fear of audits, and poor charge capture processes
Why This Matters
This pain point represents a significant opportunity for B2B solutions targeting Physicians.
Affected Stakeholders
Physicians, Coders, Billers
Deep Analysis (Premium)
Financial Impact
$100,000-200,000 annually from delayed Medicare billing + patient relations overhead • $100,000-200,000 annually from missed DPC reimbursement tiers due to under-coding + administrative overhead • $120,000-180,000 annually from missed revenue due to conservative coding + potential compliance exposure
Current Workarounds
Compliance officer maintains manual reference sheet of TRICARE coding rules; email coordination with TRICARE billing specialist; paper-based audit trail • Manual chart review to identify uncoded HCCs and under-reported complexity; spreadsheet tracking of risk adjustment opportunities; email escalations to billing • Manual comparison of contract coding requirements to submitted codes; spreadsheet-based tracking of DPC-specific compliance metrics; email communication with employer payers
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Methodology & Sources
Data collected via OSINT from regulatory filings, industry audits, and verified case studies.
Related Business Risks
Bottlenecks in Documentation-Coding Handoff
Denied Claims from Improper Documentation and Medical Necessity Issues
Extended A/R from Documentation-Related Soft Denials
Fines from Documentation Breaches Tied to Coding Compliance
Missed Charges and Coding Errors in E-Prescribing to Billing Workflow
Patient Leakage from E-Prescribing Outside Network Pharmacies
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