Most of the new physicians and nurse practitioners who joined practices in July and August finished training without a single hour of instruction on how a visit becomes a claim. They can manage diabetic ketoacidosis. They cannot tell you what separates a 99213 from a 99214, and nobody in the practice has time to teach them because the schedule filled up on day one. Ninety days later a coding audit finds every visit at 99213, no G2211, no modifier 25 on the procedure days, and diagnoses coded as "type 2 diabetes" with no complication or control status. The practice has underbilled by thousands of dollars and, more important, the provider has formed habits.
This is avoidable. The plan below takes about six hours of the provider's time over six weeks, plus two short audits. We have run versions of it for family medicine, internal medicine, pediatrics, orthopedics and behavioral health. The content changes by specialty; the structure does not. It works because it uses the provider's own notes from the first week rather than textbook cases, and because the medical director is in the room for the first and last sessions.
Key takeaways
- Teach in the credentialing gap, when the provider is on payroll but not yet billable to every payer. It is the only free time they will have.
- Six sessions of 30 to 45 minutes, each with homework drawn from the provider's own charts, cover E/M by MDM and by time, diagnosis specificity, modifiers, add-ons and denials.
- Audit ten visits at day 30 and twenty at day 90, in person, with the notes open. A spreadsheet emailed on a Friday teaches nothing.
- The five habits to break early: defaulting to 99213, timing without documenting, copying the problem list as the assessment, leaving modifier 25 to the coder, and not signing.
Before day one: a two-hour session
Schedule it in the credentialing gap. Cover four things. How a visit becomes a claim (the encounter, the code, the claim, the remittance, the denial), with your own practice's numbers: your average allowed amount, your denial rate, your days in AR. The 2021 E/M framework: level by medical decision making or by total time on the date of the encounter, and what each level requires. How your EHR captures charges and where a provider can accidentally leave a visit unbilled, because every system has at least one such place. And the practice's specific rules: who codes (provider, coder or both), how queries work, and how quickly notes must be signed.
The six weeks
| Week | Topic | Format | Homework |
|---|---|---|---|
| 1 | E/M by MDM: problems, data, risk. The difference between a stable chronic illness and one with exacerbation. Prescription drug management as moderate risk. | 45 minutes with the coding lead, using the provider's own first-week notes | Self-level ten visits before looking at what was billed |
| 2 | E/M by time: total time on the date, what counts, what does not. Prolonged services (CPT 99417, HCPCS G2212 for Medicare) and when time beats MDM. | 30 minutes | Document time on every visit for a week, then compare levels |
| 3 | Diagnosis specificity: laterality, acuity, control status, complications. Why E11.9 versus E11.65 matters for risk adjustment and for medical necessity. | 30 minutes with specialty-specific examples | Rewrite five assessments from the prior week |
| 4 | Modifiers the provider controls: 25 for a separate E/M with a procedure, 24 and 57 around globals, 95 for telehealth. What "significant and separately identifiable" looks like in a note. | 30 minutes | Review the week's procedure visits with the coder |
| 5 | Add-ons and preventive: G2211 and when it applies (proposed to become a modifier in 2027, but the documentation requirement stays), annual wellness visits (G0438, G0439) versus preventive visits, screening and counseling codes, transitional care management. | 45 minutes | Identify missed add-ons in the prior two weeks |
| 6 | Denials and queries: reading a remittance, what CO-4, CO-11 and CO-50 mean, how to answer a coder's query in under two minutes. | 30 minutes | None; the day-30 audit results are the discussion |
What the sessions look like in practice
Week one is the one that changes behavior, so here is how it runs. The coding lead prints five of the provider's notes from the first week with the billed level hidden. The provider levels each one by MDM out loud: how many problems, what kind, what data was reviewed or ordered, what the risk of management was. Then the coding lead shows what was billed. In our experience three of the five are underleveled, and the provider can see it in their own words. A patient with hypertension and hyperlipidemia, both stable, with a medication adjusted, is two stable chronic illnesses plus prescription drug management: moderate MDM, 99214. The provider billed 99213 because "it was a quick visit." That conversation, once, does more than an hour of slides.
Week three uses the same method for diagnoses. Take the assessment "T2DM, HTN, CKD" and ask three questions: controlled or not, with what complication, what stage. The answer is in the note's data, just not in the assessment. E11.65 with hyperglycemia, I10, N18.32 stage 3b. That specificity drives risk adjustment for the Medicare Advantage and ACO patients, supports medical necessity for the labs, and takes twenty seconds to write.
The day-30 and day-90 audits
At day 30, the coding lead pulls ten visits: five office visits and five procedure or preventive encounters. For each, record the billed level, the supported level, the diagnoses billed and the diagnoses supported, and any missed modifiers or add-ons. Review it with the provider in person, in a thirty-minute meeting, with the notes open.
At day 90, pull twenty. Compare with day 30. The measures that matter:
| Measure | Day 30 typical | Day 90 target |
|---|---|---|
| Agreement between billed and supported E/M level | 60 to 70 percent | 90 percent or better |
| Chronic conditions coded to full specificity | Under half | Most |
| Eligible visits with G2211 (or its successor) | Rarely | Consistent where the relationship is documented |
| Procedure days with a supported modifier 25 E/M | Inconsistent | Every visit where a separate problem was addressed, and none where it was not |
| Unsigned notes older than 48 hours | A handful | Zero |
Report the results to the provider and to the medical director. If the day-90 audit is clean, move to quarterly. If not, another six weeks, and a frank conversation about whether the problem is knowledge or habit.
The five mistakes new providers make most
- Defaulting to 99213. Residency taught them that "moderate" sounds risky. Two stable chronic conditions with prescription management is a 99214 by MDM. Show them with their own notes.
- Documenting time without documenting what was done. "Total time 42 minutes" supports a 99215 only if the note reflects the work. Auditors read the note, not the timer.
- Copying forward the problem list as the assessment. A problem list is not an assessment. Each condition addressed needs a status and a plan, and only conditions addressed are coded.
- Skipping modifier 25 because "the coder will add it." The coder cannot add it unless the note shows a separate, significant E/M. The provider has to write that note, ideally as its own assessment and plan paragraph.
- Not signing. An unsigned note is an unbilled visit. Set the expectation on day one: same day, or by the next morning at the latest, and show them the unsigned-note report that the billing office watches.
What it is worth
A new family physician seeing 18 patients a day, four and a half days a week, produces roughly 4,000 visits a year. If 30 percent of them are underleveled from 99214 to 99213 at a difference of about $38 on the Medicare fee schedule, that is about $45,000 a year, before the missed G2211 add-ons, the missed modifier 25 visits and the risk adjustment effect of unspecific diagnoses. Six hours of training and two audits against $45,000 a year, for a career, is not a close call. The habits also travel: a provider who leaves for another practice takes the training with them, which is one reason we think of it as a professional courtesy as much as a business decision.
Who teaches it
The coding lead, if you have one, with the medical director present for at least the first and last sessions so the provider hears that this is a clinical quality expectation, not a billing department demand. Practices without an in-house coder use an outside trainer or a structured course. Our live online RCM courses include a provider documentation track, and practices that want hands-on practice with a training EHR use Revelrex EHR to work through sample encounters without touching production records.
Questions we hear
Isn't this the coder's job?
The coder assigns codes to what is documented. The provider controls what is documented. A coder cannot create specificity, time or a separate E/M that the note does not contain, and a practice that relies on queries to fix every note has a coder doing two jobs and a provider who never learns.
Does this apply to APPs?
Every word. Nurse practitioners and physician assistants often arrive with even less exposure to coding than physicians, and their visits are audited the same way. Add a short session on incident-to and split or shared visit rules if your practice bills either.
What about experienced providers who joined from another practice?
Run the day-30 audit and decide from the results. Experienced providers bring the habits of their last practice, good and bad, and some of those habits were shaped by a different EHR and a different payer mix. The audit is respectful; assuming they need the full course is not.
What to do this week
- List every provider who started since June 1 and check whether any of them had a structured coding orientation. If not, schedule the two-hour session now.
- Pull five notes from each new provider's first two weeks and have the coding lead level them blind.
- Book the six sessions on the provider's calendar as protected time, with the medical director at sessions one and six.
- Set the day-30 and day-90 audit dates and put them on the coding lead's calendar.
- Print the five mistakes and give them to the provider on day one, so nothing in the audit is a surprise.
