Undercoding cost one pediatrics group more than $200,000 in unbilled vaccine claims over 18 months, according to a September 2026 presentation at the MGMA Annual Conference. On Medicare, moving one office visit from 99213 to 99214 adds $45.52, based on ClaimMax's 2026 national payment figures drawn from the CMS fee schedule.
The gap comes from habit. Coders pick the level they always pick, and no payer flags a claim that is billed too low.
What one visit level is worth in 2026
CMS released the CY 2026 Physician Fee Schedule final rule on October 31, 2025. The conversion factor is $33.4009 for clinicians outside an advanced payment model, up 3.26% from $32.35. For qualifying APM participants it is $33.5675, up 3.77%. CMS applied a 2.5% efficiency adjustment to non-time-based services in 2026, and E/M codes are exempt from it.
ClaimMax RCM lists the 2026 national non-facility payment for each established-patient level, citing the CMS payment amount files released in April 2026.
| Code | Work RVU | 2026 Medicare rate, office setting |
|---|---|---|
| 99213 | 1.30 | $90.09 |
| 99214 | 1.92 | $135.61 |
| 99215 | 2.80 | $186.00 |
| G2211 add-on | not listed | $16.57 |
Source: ClaimMax RCM, "99214 Medicare Reimbursement in 2026," citing CMS-1832-F and the CMS April 2026 payment files. National averages before locality adjustment.
The step from 99213 to 99214 is $45.52 per visit. The step from 99214 to 99215 is $50.39, and the full spread from 99213 to 99215 is $95.91. The source does not give a work RVU for G2211, so the table leaves that cell open. A practice that moves 100 established visits a year from 99213 to 99214, where the note supports it, collects $4,552 more at these rates. That is arithmetic on the table above, not a survey result.
A spine practice that billed 94% of visits at one level
Medical Economics published a case study by attorney James S. Lacy in June 2010 and updated it in December 2021. A surgical spine practice billed 94% of its office and outpatient visits as 99213. Just over 5% went to 99214. The author put the underpayment at nearly $8,000 a month, using a blended Medicaid, Medicare and commercial rate.
Over 12 months that is close to $96,000 for one practice. The article covers a single practice and does not state a sample size. The payment rates in that case are old. The pattern is the same one a level distribution report shows today: when one code holds 94% of volume, habit is driving the coding.
The vaccine gap in a 2026 MGMA talk
Barbara L. Ireland, FACMPE, a senior operations analyst at Murfreesboro Medical Clinic, presented the findings, and Medical Economics reported them on September 29, 2026. Her pediatrics group gave about 58,000 vaccine doses and billed administration for about 25,000. That is 43.1% of doses billed, and 33,000 administrations that never reached a claim.
Combination vaccines showed a second gap. The group was owed about 29,000 component units and billed about 7,000, or 24.1%, which leaves 22,000 component units unbilled. Reprocessing 18 months of claims recovered more than $200,000. Corrected billing raised the group's run rate by about $250,000 a year.
Counseling documentation moved the payment too. A vaccine visit with documented physician counseling of the family paid an average of $128. A nurse-only visit paid an average of $56. The $72 difference is 2.3 times the nurse-only rate, and the counseling has to appear in the note to count. The group built a workflow that brought physicians into the visit and added about $56,000 a year.
Add-on and preventive codes
The same talk listed smaller gains from codes that practices already had the right to bill. In one specialty, G2211 units rose from 1,802 to 11,627 in a year, a 545.2% increase, worth about $200,000 a year. Ten physicians who began billing depression screening added about $57,000 a year.
A newborn same-day evaluation and discharge code added about $57,000 a year. Billing an E/M visit alongside a well visit added about $80,000 a year after the group showed physicians how their own rates compared with their peers. Ireland told the audience, "If you're not looking, nobody else will."
The G2211 rate in the table, $16.57 per visit, shows why volume drives the result. At that rate, the 9,825 added units in the specialty above come to about $162,800 on Medicare pricing alone. The talk reported about $200,000, so the remainder likely came from other payers, though the article does not break it out.
Where to start in your own data
Two checks cost nothing beyond analyst time. Run a level distribution report by physician and compare each against the practice as a whole. Then reconcile units administered against units billed for any vaccine, drug or supply that has an inventory count. A list of add-on and preventive codes that physicians may bill, with the number of claims carrying each one, shows which codes sit unused.
Medical Economics reported that finding these gaps rarely requires new staff, software or consultants. The vaccine reconciliation is a two-column count of doses given and doses billed. The level report is a pivot table on one year of claims, with 12 months giving each physician enough visits to compare.
At the $45.52 step between 99213 and 99214, every 1,000 visits that shift by one level is worth $45,520 a year on Medicare pricing.
Sources
- Medical Economics, "If you're not looking, nobody else will: How coding habits cost practices thousands," September 29, 2026
- Medical Economics, "The High Cost of Undercoding," June 24, 2010 (modified December 23, 2021)
- CMS, "Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F)," October 31, 2025
- ClaimMax RCM, "99214 Medicare Reimbursement in 2026," 2026
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