ANAHEIM, Calif. — DoctorMGT, a medical billing and revenue cycle management company serving providers across workers’ compensation, personal injury, and specialty practices, has released new guidance addressing a costly and widespread coding error: the misuse of established patient CPT codes (99211–99215).
An internal review by the company identified that approximately 60% of providers are under-coding or over-coding established patient visits, which effectively reduces revenue, opens reimbursement windows to payer audits, and delays reimbursement. It’s not a lack of clinical documentation for many practices. It is a misunderstanding of what constitutes an “established patient” in the eyes of the payers and how much medical decision-making is required to merit each of these codes in the range.
“We kept seeing the same pattern across specialties,” said Waqas Alee, CEO of DoctorMGT. “A provider does the right work, documents it well, but picks a code that doesn’t match the visit complexity. Sometimes that means leaving money on the table. Other times it means red flags for an audit. Either way, it’s fixable, and it starts with clarity on the rules.”
The guidance explains the three-year rule used for establishing patient status, the new time-based/mdcm criteria in the current E/M guidelines, and common documentation deficiencies that result in “down coded” or “up coded” visits. Designed for practices with large patient volumes, where coding errors start to add up rapidly on hundreds of claims per month.
As the company continues to grow its educational resources for providers dealing with a continually evolving billing landscape, this release is designed to help ease the concern surrounding coding accuracy and the impact it has on claim approval and payment timeliness, especially in workers’ comp and personal injury lien billing. The company is redefining itself as more than an outsourced billing service; it is an education tool that decreases the number of denials that occur in the first place.
“Billing shouldn’t feel like guesswork,” Alee added. “Our goal has always been to give practices the tools to code confidently, whether they work with us directly or just need a clear answer. This guidance is part of that effort.”
The full breakdown, including code-by-code criteria and documentation examples, is now available on www.doctormgt.com Industry Insights hub.
About DoctorMGT
DoctorMGT is a medical billing and revenue cycle management company that specializes in workers’ compensation billing, personal injury lien billing, provider credentialing, and specialty practice billing. The company collaborates with providers in various specialties to help with claims processing, minimize denials, and recover lost revenue, which is often lost due to coding and documentation mistakes.
The solution brings together hands-on billing expertise and provider education to empower healthcare practices to thrive in an ever-changing reimbursement landscape.
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