Baseline Coding Opportunity Audit

An independent review of your urgent care E/M coding accuracy

Vantage Coding audits real urgent care charts to determine whether documented complexity is being captured in code selection — by provider, visit type, and MDM driver. Fixed fee. Structured deliverables. No ongoing commitment required.

125
Charts reviewed
5
Providers included
10 days
Turnaround after access
$4,800
Fixed fee, founding rate
Most urgent care providers document more complexity than they bill for

A single downcode from Level 4 to Level 3 costs approximately $50 per visit. Across five providers seeing 30+ patients daily, the annual leakage becomes significant — and nobody is measuring it.

The documentation is typically there. Prescription drug management, acute illness with systemic symptoms, external records reviewed, independent historian — these MDM drivers are routinely present in the chart but absent from the code selection.

Without an independent review, the pattern becomes institutional. No payer will ever send additional reimbursement for complexity that was documented but not billed.

Both the OIG and CMS recommend that all providers have their coding reviewed by an independent party with appropriate expertise, on a regular basis. Independent reviews serve to identify errors before they become embedded in organizational practice.

— OIG Compliance Guidance for Individual and Small Group Physician Practices
Typical Audit Finding — E/M Distribution
Level 3 (99213)
Billed
72%
Supported
38%
Level 4 (99214)
Billed
22%
Supported
55%
Built on the 2021+ E/M framework with MDM driver-level analysis
Every chart is evaluated against the current AMA/CMS guidelines for medical decision-making. The audit goes beyond code-level agreement to identify the specific documentation patterns that create the gap.
01

MDM-Based Code Evaluation

Each encounter is scored on the three MDM elements — number and complexity of problems, data reviewed, and risk of management — using the 2021+ framework. Code selection is based on documentation, not billing history.

02

Driver-Level Root Cause

The audit identifies which specific MDM drivers — Rx drug management, acute illness with systemic symptoms, external note review, independent historian — are most commonly present but uncaptured in code selection.

03

Provider Variance Analysis

Results are segmented by individual provider to show where the pattern is concentrated. This allows targeted follow-up education rather than a broad, unfocused training initiative.

Structured output, not a generic summary
The audit produces a complete deliverable package designed to give leadership enough evidence to make a clear decision.
01

Executive Summary

Overall findings, agreement rate, and a clear recommendation on whether a focused implementation pilot is warranted.

02

Audit Scorecard

Agreement rate, undercoded rate, overcoded rate, and accurate rate across all reviewed encounters.

03

Provider Scorecards

Individual provider variance analysis with coding patterns, accuracy rates, and the specific visit types affected.

04

Missed-Driver Analysis

Identifies which MDM elements are most commonly documented but not reflected in the billed code level.

05

Revenue Opportunity Estimate

Conservative, assumption-stated estimate of annual compliant revenue being left uncaptured, with stated reimbursement assumptions.

06

Leadership Readout

A 45-minute meeting to walk through findings, answer questions, and arrive at a go / no-go recommendation together.

Four steps from discovery to recommendation
The full engagement runs approximately three weeks from first conversation to leadership readout.
01

Confirm Fit

A 15-minute call to verify provider count, chart access path, decision-maker availability, and whether the audit scope applies to your group.

02

Execute Paperwork

Engagement letter, BAA, and invoice. The 10-day turnaround clock starts only after chart access and required data are confirmed.

03

Review Charts

125 encounters audited against the 2021+ E/M framework. Billed code, supported code, and driver flags recorded for each chart.

04

Deliver Findings

Full deliverable package plus a 45-minute leadership readout with a clear recommendation on whether to proceed.

A defined engagement with clear boundaries
Knowing what is excluded is as important as knowing what is included. This is a focused diagnostic — not an open-ended consulting engagement.

Included

  • Urgent care outpatient E/M codes (99202–99215, 99281–99285)
  • Both overcoding and undercoding detection
  • Provider-level and visit-type analysis
  • MDM driver-level root cause identification
  • Conservative revenue opportunity estimate
  • 45-minute leadership readout with recommendation

Excluded

  • Denials, appeals, rebilling, or AR cleanup
  • Hospital, facility, or inpatient coding
  • Software implementation or EHR build
  • Compliance certification or legal opinions
  • Outsourced ongoing coding services
  • Multispecialty or non-urgent-care coding review
!

This is an accuracy product, not a "bill higher" product. The review flags overcoding as well as undercoding. Revenue estimates are conservative and clearly state assumptions. If the audit finds no meaningful gap, that is still a useful outcome — you get a documented baseline and avoid investing in a pilot that wouldn't move the needle.

Fixed fee. No percentage of collections. No lock-in.
One price covers everything — chart review, all deliverables, and the leadership readout meeting. No variable fees, no contingencies.
Standard
$6,800
Fixed fee · One-time engagement
  • Up to 5 providers
  • 125 charts reviewed
  • Full deliverable package
  • 45-minute leadership readout
  • 10 business day turnaround
Get Started
What prospects usually ask before moving forward
  • Our RCM vendor already handles our coding. Why would we need an independent audit?
    RCM platforms process claims — they don't audit the clinical decision-making behind the code selection. The Level 3 to Level 4 gap lives in the MDM documentation, not in the claims workflow. An independent review examines what your billing system doesn't.
  • Do you need access to our full patient records?
    We can work with either read-only EHR access or de-identified chart packets. Most clinics choose EHR access because it requires less staff effort. All access is HIPAA-compliant with a signed BAA.
  • What if the audit shows no meaningful gap?
    That is still a valuable outcome. You get a documented baseline confirming your providers are coding accurately — which provides compliance confidence and payer audit preparedness. You avoid investing in a pilot that wouldn't have moved the needle.
  • Do you only look for undercoding?
    No. The audit evaluates both overcoding and undercoding. If providers are billing above what the documentation supports, that is flagged with the same rigor. This is an accuracy review, not an advocacy exercise.
  • Why a fixed fee instead of percentage of collections?
    Percentage-based pricing creates a financial incentive to inflate findings. A fixed fee means the recommendation is objective. If the gap is not material, you hear that directly — and you haven't overpaid for the honesty.
  • What happens after the audit?
    If findings support it, the recommended next step is a narrowly scoped implementation pilot — targeted provider education tied to the specific MDM drivers identified, followed by a re-audit to measure lift. The readout includes a clear recommendation on whether this makes sense for your group.

15 minutes to determine whether the audit fits your group

A short discovery call to confirm provider count, chart access path, and whether the scope applies. No commitment required.