26 coding tips to unlock your practice's hidden revenue potential

For most physicians, coding and documentation are necessary evils — administrative burdens squeezed into the margins of an already packed day. But the financial stakes are significant. Errors in either direction, whether undercoding out of habit or overcoding without adequate documentation, can cost a practice tens of thousands of dollars annually. Audits, claim denials and recoupment demands from payers and government programs are increasingly common, and they almost always trace back to the same root causes: vague clinical language, missed codes or documentation that doesn't reflect the complexity of care actually delivered.

The good news is that relatively small adjustments to how physicians document and code can have an outsized impact on revenue and audit resilience.

The following 26 tips, drawn from coding experts and practice management specialists, offer guidance for physicians seeking to be paid accurately for the care they provide.

1) Use time-based billing when counseling dominates the visit.

Since 2021, evaluation and management (E/M) codes can be leveled by total time, not just medical decision-making (MDM). If a physician spends 45 or more minutes on a 99214-level visit, billing to time may justify a 99215 — legally and compliantly.

“Time-based billing is still one of the most overlooked opportunities in office visit coding,” says Paul Ferrazza, vice president of CodeEMR. “Many providers continue to choose E/M levels based only on medical decision-making, even when a large part of the visit is spent counseling the patient, reviewing records, coordinating care or discussing treatment options.”

Under current E/M guidelines, providers can select the appropriate E/M level based on total physician or qualified health care professional time spent on the date of the encounter, provided documentation clearly supports both the time reported and the qualifying activities performed, according to Ferrazza.

He says that documentation should clearly specify the total time and the medically necessary work completed. For example: "Total physician time on date of service: 42 minutes, including review of prior cardiology consultation, medication reconciliation, patient counseling regarding treatment escalation and clinical documentation."

2) Stop undercoding out of fear.

Many physicians habitually bill 99213 when their documentation clearly supports 99214 or 99215. Chronic disease complexity, reviewed external records and independent interpretation of tests all count toward higher MDM levels.

“Do not compare your coding patterns [with] other providers in your specialty, as your patient population may involve significantly more complex conditions, higher acuity or multiple chronic illnesses,” says Elizaveta Bannova, a coding expert with WCH Service Bureau. “The real protection is not lower coding — it is compliant documentation, properly dated addendums, clearly established medical necessity and demonstrating how ordered services and reviewed results directly impacted the patient’s treatment goals and plan of care. Document time appropriately, separately identify time spent on counseling and coordination of care and avoid cloned notes.”

She also recommends using a reputable online E/M calculator tool to help validate code selection and support compliance.

Fear of overcoding is often unfounded.

“From a clinical denials standpoint, this is particularly significant because the complexity is often genuine: Chronic disease exacerbations, review of external records and independent test interpretation all qualify for a higher MDM level but go uncredited, and nursing documentation can support that complexity just as much as physician notes,” says Kelsey Taylor, RN, senior director, clinical denials, EnableComp. “Cigna's R49 policy, which introduced automated downcoding of high-level E/M visits when documentation does not meet AMA [American Medical Association] criteria, signals clearly where payer scrutiny is heading, even if the policy was temporarily paused following physician advocacy. The irony is that the same detailed clinical documentation that would justify a 99215 also protects you in a payer audit. Physicians who learn to trust their documentation and code to the level the record actually supports aren't just capturing more revenue; they're building the kind of clinical record that holds up under scrutiny.”

3) Document "complexity of problems addressed" specifically.

Vague phrases such as "discussed diabetes" won't support a high-complexity level. Documenting an uncontrolled chronic illness with exacerbation, or a new problem requiring additional workup, is what drives MDM up.

Ferrazza says that documentation should describe the following:

• Whether the condition is stable, worsening, uncontrolled or exacerbated
• Clinical significance of the condition during the encounter
• Whether additional evaluation is required
• Treatment modifications considered or implemented
• Impact on management decisions

Here is an example: “Type 2 diabetes with persistent hyperglycemia despite current oral medication; worsening glycemic control noted on recent labs, medication adjusted, and referral to endocrinology discussed.”

“The more clearly providers explain the status of the condition and what actions were taken, the easier it is to support the correct E/M level and demonstrate medical necessity,” Ferrazza says.

Vague documentation is one of the most consistent drivers of denials and underpayments across health care, says Zach Schultz, senior director of product policy and solutions at EnableComp.

“Payers aren't extending the benefit of the doubt,” Schultz says. “They're looking for explicit, objective evidence in the record to justify reimbursement, and phrases like ‘discussed diabetes’ don't survive that scrutiny. What makes this particularly frustrating is that the clinical complexity was real and the care was delivered; the documentation just doesn't reflect it in a way the payer can act on.”

Schultz says that from a revenue cycle standpoint, the gap between what happened in the exam room and what appears in the record is where money gets lost. Providers who document uncontrolled conditions, exacerbations and the reasoning behind their clinical decisions are the ones who hold up under audit and get paid what they're owed.

4) Don't forget the social determinants’ International Classification of Diseases, Tenth Revision Z codes.

Z55–Z65 codes (covering housing instability, food insecurity, transportation problems) are increasingly reimbursable and important for population health metrics. They take seconds to add and can affect value-based contract performance.

5) Bill prolonged services when applicable (99417).

For office visits exceeding the time threshold for 99205 or 99215, you can add 99417 for each additional 15 minutes. Few practices do this consistently.

6) Use chronic care management codes (99490, 99491, 99487).

For patients with two or more chronic conditions, CCM codes reimburse for care coordination time that is not face-to-face. Most practices leave thousands on the table each month by not billing for these.

7) Bill annual wellness visits (AWVs) separately from problem-focused visits.

AWVs (G0438/G0439) are preventive and 100% covered by Medicare. A physician can often bill a separate E/M for a new or acutely worsened problem on the same day, as long as documentation clearly distinguishes the two encounters.

“Do not use the same diagnoses for both the AWV and the problem-focused E/M service,” Bannova says. “Use preventive/wellness diagnosis codes for the AWV and separate problem-based diagnoses for the sick visit claim. Each service should have its own clearly separated documentation template, and encounter details should not overlap between the two services.”

Ferrazza says that confusion over where an AWV ends and an additional medical concern begins is common. The key requirement is that the problem-focused service must be significant, separately identifiable, medically necessary and clearly documented beyond the wellness visit itself.

“A modifier 25 is generally appended to the problem-oriented E/M code when billed on the same date as the wellness visit, when all documentation requirements are met,” Ferrazza says. Practices should avoid automatically billing a separate E/M service with every AWV. The additional service must always be supported by the documentation and medical necessity of the encounter.”

8) Add HCC-relevant diagnosis codes at every visit.

Hierarchical Condition Category (HCC) coding affects Medicare Advantage risk adjustment. Physicians should document and code active chronic conditions — not just the presenting complaint — at every visit to ensure accurate risk adjustment factor (RAF) scores and avoid midyear audits.

“If chronic conditions are not documented and coded correctly, patients may appear less medically complex than they truly are, increasing the risk of repeated payer audits, reduced reimbursement and inaccurate quality performance calculations,” Bannova says. “Many providers carry diagnoses forward without addressing them in the note, creating audit risk. HCC diagnoses must be supported by MEAT criteria [Monitored, Evaluated, Assessed, or Treated] and must be recaptured annually. Missing or unsupported diagnoses can lower RAF scores, reduce incentive payments and weaken quality metrics.”

Ferrazza agrees and provides the following example that shows a condition is clinically relevant to the visit: “Stage 3 CKD [chronic kidney disease] reviewed; renal function trends assessed, antihypertensive medication adjusted to reduce renal risk."

“The emphasis should always remain on clinically relevant documentation rather than diagnosis maximization,” Ferraza says.

9) Don't drop diagnoses that are still being treated.

Physicians frequently fail to carry forward chronic diagnoses such as hypertension or CKD when they're not the reason for the visit. These omissions suppress risk scores and can trigger payer audits or recoupments.

“This is one of the quietest yet most persistent sources of revenue erosion we encounter in our work with hospitals,” Schultz says. “When active chronic conditions aren't carried forward at every visit, risk scores are suppressed and providers become exposed to midyear audits and recoupments that are difficult and expensive to reverse. Our teams regularly identify revenue at risk during retrospective reviews, tracing it directly back to diagnoses that were actively managed but not documented at the visit level. The care was there; the record just didn't show it.”

10) Use "suspected" or "probable" diagnoses in inpatient settings.

Unlike outpatient coding, inpatient guidelines allow coding of conditions that are "probable" or "suspected" at the time of discharge, supporting more accurate diagnosis-related group (DRG) assignment.

“In our clinical validation work, we see that the diagnosis is often supported by objective evidence in the record; it just hasn't been stated with the specificity or confidence needed for accurate DRG assignment,” Taylor says. “One practical detail physicians frequently miss is that the discharge summary controls coding, not a progress note. The gap between what was documented and what the record actually supports is where revenue is lost, and physicians who understand both the guidelines and their boundaries are far better positioned to protect their DRG assignments from the start.”

11) Document medical necessity in the language of the payer's LCD/NCD.

A Local Coverage Determination (LCD) spells out the clinical language that triggers coverage. Mirror that language in your notes — not just the diagnosis code.

“Physicians should align their documentation with the payer’s language — not just list the diagnosis code — and clearly document symptoms, failed conservative treatment, severity, duration, functional limitations and why the service is medically necessary,” Bannova says.

Taylor says that payers conduct clinical validation audits against their own coverage criteria, and if your documentation doesn't use the clinical language those policies require, the risk of denial is high, regardless of how appropriate the care was.

“Mirroring LCD and NCD [National Coverage Determination] language isn't about gaming the system; it's about ensuring the legitimate care you provided is legible to the people reviewing it,” Taylor says. “Providers who build this practice into their documentation workflow see meaningfully lower denial rates on exactly the claim types that are hardest to appeal.”

12) Attach clinical notes proactively with prior authorization (PA) submissions.

Don't wait for a denial and then appeal. Submitting relevant office notes, labs and imaging with the initial PA request dramatically cuts denial rates.

13) Use the peer-to-peer request strategically.

When a PA is denied, request an immediate peer-to-peer review with the payer's medical director. Success rates for peer-to-peers are significantly higher than written appeals — and faster.

14) Track your most-denied codes and diagnoses.

A quarterly review of denial patterns reveals whether you have a documentation gap, a coding error pattern or a payer-specific policy problem. Most practices don't do this analysis.

“Tracking denial data helps identify whether the issue is caused by coding errors, missing medical necessity elements, front-end registration problems or payer-specific policy changes,” Bannova says. “Practices should regularly review denial reason codes, LCD/NCD requirements, payer bulletins and related billing articles to reduce repeated denials and revenue loss. Most importantly, practices should focus on improving internal workflows, providing ongoing staff education and implementing claim-editing processes to review and validate claims before submission.”

Brian Kenah, chief technology officer at EnableComp, points out that denial patterns are almost never random. A small number of codes, diagnoses and payer combinations account for a disproportionate share of losses, and those patterns repeat until someone surfaces them, he says.

15) Know the step therapy exception process.

Many states now have step therapy reform laws requiring payers to grant exceptions when a patient has already tried a first-line therapy without success. Documenting that failure explicitly — not just implying it — is key to winning those exceptions.

16) Bill for care plan oversight (99374-99380).

If a physician spends 30 or more minutes per month overseeing a patient in a home health agency or hospice, that time is billable — even without a face-to-face visit.

17) Use modifier 25 correctly and document it.

When a separately identifiable E/M is performed on the same day as a procedure, modifier 25 allows separate billing. But the E/M must be genuinely distinct and documented as such, or it’s an audit target.

“Modifier 25 remains one of the most frequently reviewed modifiers due to both overuse and insufficient supporting documentation,” Ferrazza says. “Modifier 25 should only be used when the same physician or qualified health care professional performs a significant, separately identifiable E/M service on the same day as a procedure. In simple terms, the visit must involve work that goes beyond what is normally included in the procedure itself.”

18) Don’t forget transitional care management (TCM; 99495, 99496).

After a hospital or skilled nursing facility discharge, TCM codes pay well and require only a phone contact within two business days and a face-to-face visit within 7 or 14 days. Many practices never bill these.

“Transitional care management is one of the most underused coding opportunities after a patient is discharged from a hospital or skilled nursing facility,” Ferrazza says. “These services recognize the extra work involved in managing a patient’s [case] during the transition back to outpatient care.”

19) Bill remote physiologic monitoring (RPM; 99453, 99454, 99457, 99458).

For patients with blood pressure cuffs, pulse oximeters or glucose monitors transmitting data, RPM codes can generate recurring monthly revenue with relatively low overhead.

20) Check for bundling edits before submitting multiprocedure claims.

Correct Coding Initiative edits bundle many procedure pairs. Knowing which modifier (59, XE, XS, XU, XP) correctly unbundles legitimate separate services — and which ones are being misused — is critical for both revenue and compliance.

21) Avoid “note bloat” that buries your actual clinical reasoning.

Auto-populated electronic health record (EHR) templates that repeat the same 14-system review every visit can hurt you in an audit — it looks implausible and obscures the real decision-making. Payers increasingly flag overly identical notes.

“Payer review focuses on whether documentation clearly supports clinical decision-making rather than note length,” Ferrazza says. “A concise, patient-specific note is usually much stronger than a lengthy note filled with unnecessary template language.”

22) Document your independent interpretation of tests — don’t just reference them.

Writing “EKG reviewed — normal sinus rhythm, no acute changes, no change from prior, plan adjusted accordingly” supports higher MDM than “EKG done.”

“When physicians independently interpret a test as part of the visit, especially when that interpretation contributes to medical decision-making, the documentation should briefly explain the findings and their clinical relevance,” Ferrazza says. “The goal is not to create lengthy interpretations, but to clearly show what was reviewed, what the physician observed, why the findings mattered clinically and how the results influenced treatment or management decisions.”

23) Use the “data” element of MDM intentionally.

Reviewing external records, ordering and reviewing tests, or independently interpreting an image all contribute to MDM data points. Document each one explicitly, not as a throwaway phrase.

“The data component of MDM is frequently underdocumented despite often contributing significantly to appropriate E/M level selection,” Ferraza says. “Statements such as ‘Labs reviewed’ do not adequately explain the physician’s analysis or clinical decision-making. A stronger statement would be: ‘Reviewed CBC [complete blood count] and metabolic panel trends from prior visits and compared findings with nephrology recommendations. Results influenced antihypertensive medication adjustment and renal monitoring plan.’”

24) Date and time-stamp addenda properly.

If you need to add to a note after the fact, a properly signed and dated addendum is legally and compliantly fine. An unsigned, undated alteration is not. EHR training on this is often insufficient.

“An addendum should clearly identify what information was added, why it was added and who entered it,” Bannova says. “Late entries that conflict with the original documentation, modify medical necessity after a denial or lack clear audit trails can increase compliance risk, trigger recoupments and weaken the defensibility of the medical record.”

Ferrazza says that providers should also avoid adding information solely to support a higher level of billing if the original documentation did not support the service performed at the time of the encounter.

25) Conduct an annual self-audit of your top five billed codes.

Pull 10 charts per code and ask: Does my documentation support this level? This is exactly what a recovery audit contractor would do, and it's the single most effective way to catch patterns before they become a recovery audit.

“If deficiencies are identified, practices should immediately implement a corrective action plan that includes provider education, focused retraining, coding review sessions, updated templates, EHR workflow improvements and prebill claim audits,” Bannova says. “Repeat audits should be conducted within 60 to 90 days to monitor improvement and confirm corrective measures are effective.”

Ferrazza says that beyond revenue integrity, proactive auditing demonstrates strong compliance oversight and strengthens preparedness for payer audits and internal compliance review.

26) Use diagnosis codes to their highest specificity.

"Diabetes mellitus" (E11.9) is far less defensible — and less useful for population health and risk adjustment — than "Type 2 diabetes with diabetic chronic kidney disease, stage 3" (E11.65 + N18.3). Specificity protects you and pays you.

“Diagnosis specificity is essential for accurate reimbursement, risk adjustment, quality reporting and audit defensibility,” Ferrazza says. “The key is that specificity must come from provider documentation. It should never be assumed or added without clinical support.”

Schultz says that from a revenue cycle perspective, underspecified coding creates a chain reaction: suppressed HCC risk scores, inaccurate DRG assignments and claims that don't survive payer scrutiny because the code doesn't reflect the actual complexity of the patient's condition.

“The difference between a generic diabetes code and one that captures the specific complication and comorbidity isn't a technicality; it represents real revenue and real audit risk,” Schultz says. “We regularly see the downstream consequences of this when working with health systems on denial prevention and revenue recovery. Providers who code to the highest level of specificity protect themselves financially, get paid accurately for the care they delivered and contribute to the population health data that increasingly drives value-based contract performance.”