New findings show family practices are losing revenue and inviting payer scrutiny when a preventive exam and a problem-oriented visit happen on the same day.
ANAHEIM, Calif., October 30, 2026 – A patient presents for her annual physical exam. She mentions her B.P. is on the rise halfway through, and the doctor takes a break to deal with that. It’s good medicine.
The Anaheim, Calif.-based medical billing, coding, and revenue cycle management company, DoctorMGT (Doctor Management Services), today announced the results of an audit of E/M (evaluation and management) coding on family practice claims [sample size and date range]. Documentation failed to meet the requirements to support the claim in approximately 1/3 of visits when combined with a separate problem-oriented service.
Any of you who’ve been billing primary care are familiar with the situation. The wellness exam is included in a preventive code (99395 or 99396).
A problem-oriented code (99213 or 99214) includes the additional work, and modifier 25 lets the payer know that the work was significant and separately identifiable. If it’s not backed up by the note, there are typically two ways practices go. They downcode, play it safe and give away the revenue, or they bill both and wait to receive the denial or the records request.
“Physicians are doing the work. The note just doesn’t show it,” said Waqas Alee, CEO of DoctorMGT. “We keep seeing charts where a provider clearly managed a real problem during the visit, but it’s folded into the preventive note. A payer reading that can’t tell where one service ends and the other begins, and in a review, the benefit of the doubt doesn’t go to the practice.”
Auditors kept running into the same five gaps:
- Preventive and problem-oriented work blended into one section of the note
- No separate assessment and plan for the problem addressed
- Modifier 25 attached with nothing in the chart to support it
- Medical decision-making too thin to justify the E/M level billed
- No time documented to fall back on when decision-making is light
The timing matters. Every records request can consume the entire billing team’s time for days, and payers watch modifier 25 closely. That expense doesn’t actually appear on the claim if it is a practice that is already low on staff.
The fix is no more than physicians are being asked. DoctorMGT’s coders suggest separating templates so preventive documentation sits in distinct sections from problem-oriented documentation, documenting decision-making or time each time a problem is addressed, and scheduling audits for high-volume visit types rather than after denial. “Most of these practices don’t have a coding problem.
They have a problem with their note structure,” said Alee. Set up the template, reinforce the habit, and the money will follow.
“Most of these practices don’t have a coding problem. They have a note-structure problem,” Alee said. “Fix the template, tighten the habit, and the revenue follows.”
Practices that want to see where they stand can contact doctormgt.com. The company’s team of 800+ certified billers and coders supports providers across 20+ specialties, with a dedicated biller assigned to every client.
About DoctorMGT
DoctorMGT (Doctor Management Services) is a medical billing, coding, credentialing & revenue cycle management company based in Anaheim, California. The company focuses on workers’ compensation & personal injury lien billing and specialty practice management solutions for providers to enhance cash flow, minimize denials, and remain compliant.
Contact:
DMS Press, Media Relations
201 E Center St Suite 112, Anaheim, CA 92805, United States
Tel: (+1) 657-999-7255
Email: info@doctormgt.com
Website: www.doctormgt.com