Episode 194: Most of Your Visits are Actually 4’s – Why Is Everyone Still Coding 3’s?
What if I told you that you could increase your income by thirty thousand… fifty thousand… maybe even eighty thousand dollars a year… without seeing a single additional patient?
Would you believe me if I told you the answer isn’t working harder, squeezing in one more patient, staying later at the office, or sacrificing another evening with your family?
What if I told you the answer is simply documenting the work you’re already doing and allowing yourself to be paid appropriately for it?
If that sounds too good to be true, stay with me, because today we’re talking about one of the biggest financial leaks we see in physician practices across the country. It’s not declining reimbursement. It’s not staffing shortages. It’s not rising overhead. Those are certainly challenges, but there’s another issue that quietly costs physicians tens of thousands of dollars every year.
It’s undercoding. Specifically, physicians who are providing Level 4 care but continue to bill Level 3 visits out of habit, fear, or simply because no one ever taught them differently.
If you’ve ever finished a full day of clinic, felt mentally exhausted, looked at your schedule, and wondered, “How am I working this hard and still feeling like my practice isn’t where it should be financially?” then this episode is for you.
One of the things I’ve learned after working with physicians for years is that doctors are incredibly good at taking care of everyone except themselves. You’ll advocate tirelessly for your patients. You’ll spend extra time explaining treatment options. You’ll call a family after hours because you’re worried about someone. You’ll lose sleep over difficult cases. But when it comes time to value your own work? Many physicians suddenly become hesitant. They’re afraid they’ll bill too much. They’re afraid they’ll attract an audit. They’re afraid someone will think they’re greedy. And because of that, they quietly leave money on the table every single day.
Let me paint a picture that may sound familiar. A patient comes into your office with diabetes, hypertension, chronic kidney disease, and worsening fatigue. You review laboratory results that were performed somewhere else. You reconcile medications. You adjust treatment. You discuss whether additional testing is necessary. You talk about warning signs that should prompt an emergency department visit. You coordinate follow-up care and answer several thoughtful questions from the patient and their spouse. You spend twenty-five or thirty minutes thinking through that patient’s care. You use your years of education, your clinical judgment, and your experience to make decisions that truly matter. Then you finish your note and almost automatically click 99213. Not because that’s what the visit deserved. Because that’s what you’ve always done. Or because someone once told you to “play it safe.” Or because you don’t want to deal with questions from your coder later. Sound familiar?
Here’s what I want you to hear today. This isn’t about learning how to bill more. It’s about learning how to stop giving away the care you’ve already provided. There’s a tremendous difference between aggressive billing and accurate billing. No one is suggesting you bill a Level 4 when the documentation doesn’t support it or to stretch the rules. As we like to say, compliance is table stakes. We’re talking about accurately capturing the complexity of the work you perform every single day.
The reality is that medicine has changed dramatically over the past decade. Patients are older. In most cases, your entire practice has been aging with you. So, they’re more medically complex. They’re taking more medications. They have multiple chronic illnesses. Care coordination has become a larger part of your day.
You’re reviewing outside records, laboratory studies, imaging reports, consultant notes, and hospital discharges. You’re making thoughtful decisions about risk. You’re counseling patients through increasingly complicated medical situations. That’s not simple medicine anymore. For many physicians, that’s Level 4 medicine. All. Day. Long. Yet so many continue to code as though every visit is straightforward. Why? Part of the answer is simple. Medical school didn’t teach you this. Residency didn’t teach you this. You spent years mastering anatomy, physiology, pathology, diagnosis, procedures, communication, and patient care. You learned to make life-changing decisions under pressure. You became experts in your specialties. Then you’re handed the keys to practices that generate millions of dollars in revenue and expected to magically understand coding, reimbursement, compliance, documentation, staffing, contracts, payer policies, and business operations almost by osmosis. That isn’t a personal failing. It’s a training gap. And unfortunately, many physicians have been carrying that gap throughout their careers.
Another reason physicians undercode is fear. I’ve heard it hundreds of times. “If I bill more Level 4 visits, won’t I get audited?” That’s probably the single biggest misconception I hear. Auditors are not looking for physicians who appropriately bill Level 4 visits. They’re looking for documentation that doesn’t support the code submitted. Those are completely different things.
If your documentation accurately reflects the medical decision making, the risk, the data you reviewed, and the complexity of the encounter, accurate coding isn’t something to fear. In fact, good documentation is your best protection. Unfortunately, somewhere along the way many physicians were taught that the safest approach was simply to bill lower than necessary.
Let’s think about that for a moment. Imagine another profession intentionally undercharging because they’re afraid someone might question their invoice. Would you expect an attorney to bill for one hour after spending three? Would you expect an architect to charge for a simple sketch after designing an entire building? Of course not. Yet physicians do something remarkably similar every day. Not because they’re dishonest. Because they’re humble, cautious, and genuinely want to do the right thing. But doing the right thing also includes accurately reflecting the care you provided.
And there’s another fear that doesn’t get discussed often enough. Many physicians worry they’ll be perceived as money-grubbing if they bill appropriately. That concern is understandable because medicine has always been viewed as a calling. Most physicians entered healthcare because they wanted to help people, not because they wanted to become experts in reimbursement.
But here’s something I’d like you to consider. Charging appropriately for the care you’ve already provided doesn’t make you greedy. It makes you sustainable. Every dollar your practice earns supports your ability to continue caring for patients. It pays your nurses, medical assistants, front office staff, technology, equipment, rent, malpractice insurance, and every other resource required to provide excellent care. Healthy practices create healthier communities. And that starts with allowing your practice to remain financially healthy.
Before we continue, I want to share something that may change the way you think about coding forever… Most of your visits are probably already Level 4 visits. You just haven’t allowed yourself to recognize them. When we work with physicians and we begin reviewing charts together, we often hear the same reaction:
- “I had no idea that qualified.”
- “I’ve been doing that for years.”
- “I thought I needed to document a lot more.”
Or my favorite:
- “I’ve been leaving money on the table this whole time.”
Unfortunately, yes. And, if it’s any consolation, you’re certainly not alone.
Let’s do some simple math. Imagine you’re undercoding just four patients each day. Not twenty. Not half your schedule. Just four. Now multiply that over five clinic days a week. Then multiply that over 48 working weeks in a year. Depending on your specialty and payer mix, you’ve suddenly created a revenue gap that can easily reach $30,000 a year. For many physicians, it’s $50,000. Some practices discover the number is closer to $80,000 annually that you could recoup.
Reflect on that again. Without seeing another patient, adding clinic hours, hiring another clinician, increasing burnout, or sacrificing another evening with your family. You’re simply being compensated appropriately for the work you’re already doing.
Think about what that could mean. Maybe it allows you to finally hire another medical assistant who’s desperately needed. Maybe it lets you invest in technology that saves everyone time. Maybe it funds retirement. Maybe it pays for your children’s education. Maybe it simply gives you the financial breathing room that so many physicians have been missing. That’s why this conversation matters. This isn’t just about reimbursement. It’s about sustainability.
Another obstacle I see all the time is what I call “defensive coding.” Many physicians have worked with coding specialists or compliance departments that seem to believe the safest answer is always the lower code. Now, let me be very clear. Compliance professionals serve an important purpose. Every practice needs people who understand regulations and help reduce risk. But sometimes the culture shifts from compliance to unnecessary caution. Every chart gets questioned. Every Level 4 becomes a Level 3. Every discussion starts with, “Let’s just be conservative.” I understand why that happens. Nobody wants an audit, repayment demands, or uncomfortable conversations. But compliance doesn’t mean consistently choosing the lower code. Compliance means accurately representing the care that was provided. Not higher. Not lower. Accurate. If a visit truly meets the criteria for a Level 4, billing a Level 3 isn’t more compliant. It’s simply inaccurate in the opposite direction. It is actually fraudulent to undercode too. And inaccurate coding – whether it’s too high or too low – isn’t the goal. Accuracy is.
One of the things we love teaching physicians is that good documentation doesn’t have to mean longer documentation. In fact, some of the strongest notes we review are remarkably concise. They’re organized. They’re intentional. They clearly communicate the physician’s medical decision making. They capture the complexity. They explain the risk. And then they move on. Many physicians believe they need to write novels to support higher-level coding. You don’t. What you need are the right words, phrases, structure, and workflow.
Think about your electronic health record for a minute. Is it working for you? Or are you working for it? For many physicians, the EHR has become little more than an expensive typewriter. Hours spent clicking boxes, copying old notes, and typing the same sentences over and over again. That’s exhausting. But it doesn’t have to stay that way. One of the biggest “aha” moments physicians experience is realizing how much time they can save by building effective Quick Text, Smart Phrases, templates, and documentation shortcuts that actually support appropriate coding.
Imagine having a handful of carefully written phrases that accurately describe common clinical situations. Imagine documenting your medical decision making in seconds instead of minutes. Imagine your note naturally supporting the code because the language is already there. That’s not gaming the system. That’s building an efficient system.
Physicians should never have to choose between efficiency and compliance. With the right tools, you can absolutely have both. That’s exactly why we developed CodeMastery. Not because physicians need another complicated course. Quite the opposite. Physicians are busy. The last thing you need is another hundred-hour educational program that leaves you with more information than practical skills. Given everything we’ve talked about so far, you can absolutely build your own coding review processes internally and do some training in house. Or, you can outsource.
We designed our CodeMastery program to be efficient, practical, and immediately useful. It’s physician-to-physician focused education taught by physicians in a language that physicians understand. You’ll learn the current evaluation and management guidelines—not outdated rules from years ago. You’ll learn how to recognize when a visit truly qualifies as a Level 4 and, just as importantly, when it doesn’t. Or when it should actually be a 5!
You’ll learn how to document smarter instead of longer. You’ll learn how to reduce the anxiety surrounding audits by understanding what documentation actually supports your coding decisions. You’ll get high octane Quick Text phrases that save time while strengthening your documentation. And perhaps most importantly, you’ll begin to replace uncertainty with confidence.
Confidence changes everything. Instead of wondering whether you chose the right code, you’ll know. Instead of hoping your documentation is enough, you’ll understand why it is. Instead of second-guessing yourself every evening, you’ll be able to move on to the next patient knowing you’ve accurately reflected the care you provided. There’s something incredibly freeing about that. Because at the end of the day, this isn’t really a coding conversation. It’s a value conversation. How do you value your own expertise? How do you value decades of education? How do you value the judgment that allows you to recognize subtle clinical changes before they become catastrophic? How do you value the responsibility you carry every single day?
Patients value it. Your colleagues value it. Your family certainly values the sacrifices you’ve made to become a physician. The only question left is whether you’re allowing your documentation to reflect that value.
If today’s episode has you thinking, “I wonder if I’m one of those physicians who’s been consistently undercoding,” I encourage you to be curious rather than critical. This isn’t about guilt. It’s about opportunity. Opportunity to strengthen your practice. Opportunity to reduce unnecessary financial stress. Opportunity to create resources that ultimately allow you to care for patients even better. And if you discover that you’d like some guidance, we’d be honored to help.
At Health e Practices, we’ve worked with physicians and medical groups across the country who simply wanted to understand the business side of medicine a little better. Whether it’s coding, documentation, revenue cycle performance, or broader operational challenges, our goal has always been the same: to help physicians build healthier, more sustainable practices so they can continue doing what they do best—caring for patients. You can use our tools to get your Undercoding Insights Report at our website: www.healtheps.com and click on CodeMastery in the top menu. It will let you know based upon your current coding if you’ve got opportunity to earn more.
Remember, you don’t have to become a coding expert overnight. You don’t have to memorize every guideline. You don’t have to spend weeks studying. Sometimes a few focused hours learning from physicians who understand both medicine and documentation can completely change the trajectory of your practice. Most importantly, stop apologizing for the value you bring. You earned your education. You earned your experience. You earned your clinical judgment.
Now make sure you’re documenting – and coding – the care you already provide. Because valuing your work isn’t about making medicine more expensive. It’s about making sure physicians have the resources they need to continue practicing excellent medicine for years to come.
Thank you for spending part of your day with me. I hope today’s conversation encourages you to take a fresh look at your documentation, your coding habits, and perhaps most importantly, the incredible value you bring to every patient encounter. And if I sound like I’m passionate about this, I am! I want you to get paid for the care you deliver.
Until next time…