The $145,000 you already earned and did not get paid for
In fellowship, I watched nearly every attending code a level 3 for almost every visit. Not because the visits were simple. Because a level 3 felt safe and took no thought.
I did exactly the same when I started practice, for the same reason, until a missed bonus made me look at the math. This is not a failing of careless physicians. It is the water we swim in, and almost nobody stops to question it until something forces them to.
- Accurate coding is not coding higher. It is getting credit for work you have already done.
- The gap is almost always a few sentences in the note, describing things that actually happened in the room.
- This guide shows you where the money quietly leaks, and the small habit that stops it.
Most providers assume someone else is handling the coding. You see the patients, write the notes, and trust the system to take it from there. That trust is usually misplaced, not because coders lack skill, but because accurate coding requires knowing what happened in the room, and only you know that.
When the system gets it wrong, it almost always errs in one direction: lower than what you earned. Overcoding tends to get flagged. Undercoding just gets paid quietly.
How a code becomes your paycheck
Every encounter you have, every office visit, procedure, and hospital evaluation, is assigned a CPT code. That code carries a set number of work relative value units, or wRVUs. Your employer or payer multiplies those wRVUs by a conversion factor to decide what the work is worth.
In most employment contracts, your total wRVU count also decides whether you clear the productivity thresholds that unlock bonus pay.
The code submitted is not chosen at random. It reflects whatever the documentation supports. If your note supports a level 4 established visit (99214), that is the code that goes out. If the note is ambiguous and a cautious coder assigns a level 3 (99213) instead, you just lost 0.62 wRVU on that encounter.
| CPT | Established visit | wRVU | Difference from 99213 |
|---|---|---|---|
| 99213 | Low complexity | 1.30 | n/a |
| 99214 | Moderate complexity | 1.92 | +0.62 per visit |
| 99215 | High complexity | 2.80 | +1.50 per visit |
At 20 established visits a day, the gap between always coding 99213 and accurately coding 99214 is about 12 wRVU a day, roughly 62 a week, and close to 2,900 a year. At $50 per wRVU, that is about $145,000, for the same work.
"Undercoding usually just gets paid quietly, and nobody calls to tell you what you left behind."
Why "just code a 3" feels safe, and costs you
Undercoding is not a character flaw. It is a rational response to a system most providers were never taught. Medical school includes no coding curriculum. Residency almost never teaches it. You arrive in practice, get handed an electronic record, and are told to document appropriately, a phrase that means something very specific in coding that nobody spells out.
So providers default to conservative codes, because conservative codes feel safe. A level 3 never triggers an audit the way a level 5 might. What rarely gets counted is the cost of the other direction: undercoding suppresses your productivity metrics, can affect your bonus, and makes the effort you pour into complex patients invisible to the system measuring your work.
There is also a documentation gap. Many providers write notes that capture their thinking but do not spell out the elements the coding system needs to see. A note that says "discussed options, plan as above" records real work, but it gives a coder nothing to support a higher level. The fix is usually a few sentences about the problems addressed, the data reviewed, or the risk in the plan.
Accurate, not aggressive, not timid
The legal and professional standard is accurate coding. Not aggressive, not conservative. Accurate. Overcoding, claiming more than the encounter supports, is improper, and in egregious cases it is fraud, with consequences that can include repayment demands, exclusion from Medicare, and in extreme cases criminal liability.
But undercoding is not the safe harbor many assume. Systematically recording less than you provided also misrepresents the encounter and distorts the record. The claim is supposed to reflect what happened. That is the whole standard, and it runs both ways.
So when this guide talks about closing the gap between the work you do and the credit you receive, it is not a strategy for squeezing the system. It is what accurate coding looks like for providers who have been drifting below it for years without knowing.
The three objections, answered
"Isn't this the coders' job?"
Coders do skilled work, but they can only code what your note documents. They were not in the room. When the note is ambiguous, they make the cautious call, because that is the safe call for them. You are the one who absorbs the cost.
"I'm salaried, so RVUs don't matter for me."
Your wRVU production is almost always tracked anyway, and it surfaces in your annual review, your contract renewal, and your bonus eligibility. Numbers that undersell your work weaken your position every year, often without you knowing why.
"I don't have time to learn this."
The core is a handful of concepts, and the habit change is a few extra sentences per note describing things you already did. Most providers find the framework takes an evening to grasp and a couple of weeks to make automatic.
Why now
The 2021 overhaul of E/M rules simplified office visit coding. The old system made you count bullet points in the review of systems and exam. The new system asks a more honest question: how complex was the decision you made?
Providers who understand the new rules can document naturally and still land the correct code. Providers working on old assumptions often do extra documentation work and still get the wrong one. The learning curve is real, but it is short.