Most providers receive some version of a monthly or quarterly productivity report from their employer. Most of the time, they look at the total wRVU number, compare it to their threshold, and move on. That is a missed opportunity. The distribution of codes in that report is a diagnostic tool, it tells you specifically where your documentation is costing you productivity.
What Data You Need
Request from your billing department or practice administrator a report that shows, for a rolling 3–6 month period:
- Your submitted CPT codes (not just E/M codes, all codes)
- The number of units of each code billed
- The wRVU value associated with each
- If possible, the date of service for each claim
Most your record system environments and practice management systems can generate this report. If your billing team cannot produce it, ask for a raw export of your charges for the period and you can analyze it yourself.
What to Look For: The E/M Distribution
Start with your E/M code distribution. Count the number of 99212s, 99213s, 99214s, and 99215s you billed for established patients. Calculate what percentage of your established patient visits fell at each level. Then compare that distribution to the national benchmark for your specialty, MGMA publishes specialty-specific E/M distributions annually, and your billing department may have access to these or to your payer's own benchmarks.
If your 99213 percentage is significantly higher than the specialty benchmark, that is the primary gap to investigate. Pull a sample of those notes and apply the MDM table: do they actually meet only low complexity? Or are there two chronic conditions being managed, prescription medications adjusted, data reviewed, the indicators of moderate complexity that support 99214?
Procedure Code Analysis
For the specialty-specific guides in this chapter (Chapters 25–19), pull your procedure codes and ask a few specific questions:
- What is your ratio of guided to non-guided injection codes (20611 vs. 20610)? If you use ultrasound routinely, this ratio should reflect that.
- How often does a procedure visit include a Modifier 25 E/M? If the answer is rarely or never, audit a sample of procedure visits to confirm whether a separate evaluation occurred that was not captured.
- For fracture care: are your manipulation codes being billed when manipulation was performed? Or are you defaulting to no-manipulation codes?
The Modifier 25 Check
Pull every visit where a procedure code was billed without a Modifier 25 E/M. Read the clinical notes for a sample of these. How often did you document a clinical evaluation that was distinct from the procedure decision? That is your Modifier 25 gap, the visits where the evaluation happened and was not captured in a separately billed E/M.
Tracking Over Time
Once you have a baseline, track your distribution monthly. After any documentation intervention, whether a documentation template change, a coding education session, or a workflow modification, the impact should be visible in the data within 30–60 days. This feedback loop is the most powerful driver of sustained improvement: you see the result of the behavior change, and that result motivates the next iteration.
One Final Thought
This book started with a simple premise: you are already doing the work. You are seeing the patients, making the decisions, writing the notes, performing the procedures. The gap between what you are getting credit for and what you have earned is not a gap in your clinical effort, it is a gap in how that effort is documented and coded.
Closing that gap does not require working harder. It requires understanding the system well enough to document your work in a way it can recognize. That is the whole point of everything in this chapter: not more work, but appropriate credit for the work you are already doing.