‘If you’re not looking, nobody else will’: How coding habits cost practices thousands

Physician practices may be losing hundreds of thousands of dollars a year for care they already provide, simply because of coding habits no one has questioned, a longtime practice administrator said.

Finding that money rarely requires new staff, software or consultants. It takes a basic charge report, a spreadsheet and a willingness to ask physicians and coders why their billing patterns differ from their peers’.

“Many opportunities people assume would require consultants, special software, or advanced analytics, but are actually sitting in reports that they already have access to. It’s simply knowing where to look,” said Barbara L. Ireland, FACMPE, senior operations analyst at Murfreesboro Medical Clinic.

Ireland presented “What’s Hiding In Your Data? Using the Right Data to Discover Hidden Revenue Opportunities” on Sept. 29 at the Medical Group Management Association (MGMA) 2026 Annual Conference in San Antonio. She has more than 20 years of experience in health care administration and is immediate past president of Tennessee MGMA. She noted that names and identifying details in her examples were changed, but “the stories and results are real.”

Where is the missed revenue?

Ireland’s method started with a standard report most practice systems can produce, listing providers, dates of service, Current Procedural Terminology (CPT) codes, payers, charges, payments and adjustments. She loads it into an Excel PivotTable spreadsheet with physicians down the side and billing codes across the top, then scans for variation among physicians in the same specialty who see similar patients.

Some differences are expected. Large gaps, such as a code most physicians use regularly and a few never bill, or two codes that normally appear together but don’t, prompt her to ask why. She also compares each physician’s current patterns with his or her own prior year.

“Variation doesn’t automatically mean someone is right or wrong. It simply tells us where to look,” Ireland said.

Are your coders afraid to bill?

When Ireland began sitting down with coders, she found that many saw themselves as claim processors or gatekeepers rather than physician advocates. Some skipped codes because “the doctor didn’t select it,” because a payer had once refused to pay, or because a charge seemed too small to matter. Some told her they didn’t want to get in trouble or “go to jail.”

Meanwhile, physicians assumed coders would catch anything they missed.

Combined, organizations miss out on revenue due to “an overwhelming risk aversion” that sets in, Ireland said. She pointed to American Medical Association (AMA) guidance that the physician is responsible for documenting the service and for a correctly coded claim, while the coder accurately translates that documentation into codes.

“That is not an adversarial relationship; it’s a partnership,” she said.

To make that partnership explicit, Ireland wrote a two-page physician/coder agreement. It isn’t a legal contract. But the written document spells out each side’s responsibilities and asks physicians how they want coding questions handled, whether coders should fix a code and notify them, ask first or send educational feedback. The biggest effect, she said, was giving coders permission to speak up.

How much was the work worth?

Ireland walked through several cases in which the work was already being done. Each result came with no added staff or expense.

Coders at one organization misunderstood the intended use of G2211, a visit complexity code Ireland said is used for long-term patient relationships, and were working from outdated guidelines. After she shared research and education, use of the code rose from 1,802 units in one year to 11,627 the next, adding roughly $200,000 in annual revenue for one specialty.

In a pediatrics group, some physicians didn’t bill a depression screening code because the screen seemed too easy when results were negative or because patients complained about the charge. Ireland emailed them the numbers “just an FYI,” showing the patient cost for one payer was $1.24 on a $35 charge. Ten more physicians began billing the code, adding about $57,000 a year.

Coders in another group didn’t know about a code for evaluating and discharging a newborn on the same day, believing they could bill for one service or the other. Once they began using it, the code added about $57,000 the following year.

She also found that 75% of physicians in one group almost never billed an evaluation and management (E/M) service alongside a well visit when additional necessary work was performed. After she shared peer comparisons, the financial impact and education, a follow-up analysis a year later showed about $80,000 in added annual revenue. Not every physician changed, and Ireland said that’s acceptable.

“My goal isn’t to force providers into any particular practice style. I simply provide information and help them make informed decisions,” she said.

What did vaccine coding reveal?

In another pediatrics group, Ireland counted about 58,000 vaccines given but only about 25,000 administration codes billed. Roughly 29,000 component units should have been billed for combination vaccines, but only about 7,000 were. Coders said they billed a maximum of two components per vaccine because that’s what they had been told. Ireland found current guidance didn’t support the limit, retrained the team and rebilled 18 months of claims, recovering more than $200,000. The practice now gains about $250,000 a year.

The same data showed vaccine administration paid an average of $128 when a physician counseled the family, compared with $56 for the same vaccines given at a nurse-only visit. Many physicians then worked out a simple workflow change with their nurses. When a child came in only for shots, the physician briefly stepped in to counsel the parent and documented it. That added about $56,000 a year, and patients liked seeing their physician again, Ireland said.

Who is looking out for your revenue?

Ireland urged practices to submit their CPT utilization data to MGMA DataDive, which she said gives participants free access to benchmarking data. Many physicians, she said, are doing work for free because they don’t know about newer codes covering long-term patient relationships, communication outside the visit, device monitoring, education and counseling

In one group, coders left CPT 99459, which Ireland said helps cover the added cost of performing Pap smears, off claims because they assumed it must be bundled and wanted to avoid denials. She said the code should be billed unless payer policies state otherwise, and she urged organizations not to hold denial rates against their coders.

Ireland asked for a show of hands from administrators who ever got a call from a payer to notify them that a practice billed a lower-paying code than it could have, or forgot a billable service. There were no takers in the room.

“The reality is simple: Payers are responsible for paying according to the claim submitted. … They’re not responsible for maximizing your reimbursement. We are,” Ireland said. “If you’re not looking, nobody else will.”

Medical Economics is in San Antonio at the MGMA Annual Conference, Sept 27-30, celebrating 100 years of MGMA, attending sessions and speaking with industry leaders. Follow our coverage on our MGMA conference page.