1 in 3 E/M Visits Is Coded at the Wrong Level. Here's What That's Costing Orthopaedic Practices.

When Maia's AutoCoder reviews orthopaedic E/M encounters against the clinical documentation, it finds that the E/M level is incorrect roughly 35% of the time.

Sit with that for a moment. Not 35% of difficult cases. Not 35% of new-patient visits. Across E/M coding broadly, more than one in three encounters is leveled wrong relative to what the note actually supports.

This isn't a knock on coders or physicians. E/M leveling is genuinely hard. The criteria around medical decision-making and time are nuanced, they've shifted in recent years, and they have to be applied consistently across every encounter, every day. When you're moving fast through a full clinic schedule, the level that gets selected and the level the documentation justifies drift apart in both directions.

Wrong in both directions

A 35% error rate doesn't mean 35% undercoding. It cuts both ways, and each carries a different cost:

Undercoded visits quietly under-reimburse work that was genuinely done and documented. The note supports a higher level; the claim doesn't capture it. That revenue is simply left on the table, visit after visit.

Overcoded visits create compliance exposure and denial risk. A level that outpaces the documentation is exactly what payers look for, and exactly what's hardest to defend when they push back.

Either way, the claim doesn't reflect the reality of the encounter. And in orthopaedics, where E/M volume is high, a one-in-three leveling error rate compounds into a material number fast.

How AutoCoder fixes this problem at the source

Maia's AutoCoder reads the clinical note directly from your EHR and independently determines the correct E/M level. It factors in both the time spent on the case and the medical decision-making criteria documented in the note. It doesn't echo back the level a provider selected; it derives the right level from the documentation itself and flags where the two disagree.

The output tells your team exactly where to look:

Green: the level matches the documentation. No action needed.

Yellow: close, but the documented medical decision-making or time doesn't fully support the level. One click to review.

Red: the selected level isn't supported. Flagged for correction before the claim goes out.

Your coders stop auditing every encounter from scratch and start reviewing only the ones that actually need a human decision.

Three Things This Changes

Accurate coding. Every E/M level reflects what the documentation supports. No more, no less. The goal isn't to code up; it's to code right. Sometimes that means a higher level the practice earned and missed. Sometimes it means pulling a level back before it becomes a liability.

Accurate reimbursement. When the level matches the work, the claim captures the true value of the care delivered, and it stops bleeding revenue on undercoded visits while staying defensible on the rest.

A strong foundation for appeals. Because every recommendation comes with a written justification tied directly to the note, you're not scrambling to reconstruct your reasoning when a payer challenges a claim. The documentation-to-code link is already built. If you need to appeal, you're starting from a position of strength instead of assembling the case from nothing. That matters when appeals already cost 30 to 60 minutes of hands-on administrative time each, plus physician and staff hours.

The Bigger Picture

A 35% E/M leveling error rate is the kind of structural leak that's invisible on any single claim and enormous in aggregate. It doesn't show up as a crisis. It shows up as a practice that's quietly under-reimbursed, occasionally over-exposed, and always one payer audit away from an uncomfortable conversation.

AutoCoder closes that gap at the point of coding: accurate levels, accurate reimbursement, and a clean, defensible record behind every claim. Book a demo of AutoCoder today.