E&M Coding in Orthopaedics: Why Most Groups Undercode—and How to Fix It

Most orthopaedic groups undercode their E&M visits, leaving millions in earned revenue uncaptured across the specialty every year. In this episode of the Maia Webinar Series, orthopaedic surgeons Dr. Salman Chaudri and Dr. Nicholas Strasser join host Zach Ruhl to unpack why E&M coding is so consistently underdone—and what practices can do about it.

The conversation gets honest about a problem most physicians recognize but rarely discuss: coding was never taught in residency, the guidelines remain frustratingly unclear, and the fear of defrauding Medicare pushes well-meaning surgeons to intentionally undercode their work.

What we cover:

Why E&M is high-volume, high-complexity, and frequently undercoded

The 2021 and 2023 guideline changes and what they mean for documentation today

The gap between how physicians document and how coders interpret that documentation

Why injections and procedures create denials when E/M justification is missing

How to document the work you actually do to capture a level 4 over a level 3

The cost of conservative coders defaulting to safe codes on an entry-level workflow

Where AI and automation are headed—real-time coding suggestions tied to documentation, and compliance checks against current CMS and payer rules