Medical billing is the process of submitting and following up on claims with health insurance companies to receive payment for services rendered by healthcare providers. The process begins when a patient receives care, continues through coding and claim submission, and ends when payment is received and posted. Key steps include patient registration, insurance verification, charge capture, coding (CPT and ICD-10), claim submission, payment posting, and denial management.
Medical billing is the process of submitting and following up on claims with health insurance companies to receive payment for services rendered by healthcare providers. The process begins when a patient receives care, continues through coding and claim submission, and ends when payment is received and posted. Key steps include patient registration, insurance verification, charge capture, coding (CPT and ICD-10), claim submission, payment posting, and denial management.
The claim appeal process typically follows these steps: (1) Review the denial reason code and EOB/ERA; (2) Determine if the denial is correctable by resubmission or requires a formal appeal; (3) Gather supporting documentation (medical records, authorization letters, coding rationale); (4) Submit a written appeal within the payer's timeframe (typically 60-180 days); (5) Include a cover letter referencing the claim, denial reason, and supporting evidence; (6) Track the appeal and follow up. Medicare has 5 levels of appeal. Commercial payers typically have 2-3 levels. Success rates for well-documented appeals range from 50-70%.
The claim appeal process typically follows these steps: (1) Review the denial reason code and EOB/ERA; (2) Determine if the denial is correctable by resubmission or requires a formal appeal; (3) Gather supporting documentation (medical records, authorization letters, coding rationale); (4) Submit a written appeal within the payer's timeframe (typically 60-180 days); (5) Include a cover letter referencing the claim, denial reason, and supporting evidence; (6) Track the appeal and follow up. Medicare has 5 levels of appeal. Commercial payers typically have 2-3 levels. Success rates for well-documented appeals range from 50-70%.
Claim scrubbing is the automated review of healthcare claims before submission to identify and correct errors that would cause denials or rejections. Scrubbing software checks for: (1) Valid CPT/ICD-10 code combinations, (2) Proper modifier usage, (3) National Correct Coding Initiative (NCCI) edits, (4) Missing required fields, (5) Duplicate claims, (6) Age/gender-specific code appropriateness, (7) Local coverage determinations (LCDs), and (8) Payer-specific rules. Effective claim scrubbing can achieve clean claim rates above 95%, significantly reducing denials and accelerating payment.
Claim scrubbing is the automated review of healthcare claims before submission to identify and correct errors that would cause denials or rejections. Scrubbing software checks for: (1) Valid CPT/ICD-10 code combinations, (2) Proper modifier usage, (3) National Correct Coding Initiative (NCCI) edits, (4) Missing required fields, (5) Duplicate claims, (6) Age/gender-specific code appropriateness, (7) Local coverage determinations (LCDs), and (8) Payer-specific rules. Effective claim scrubbing can achieve clean claim rates above 95%, significantly reducing denials and accelerating payment.
A charge master (also called a charge description master or CDM) is a comprehensive listing of all billable items and services offered by a healthcare provider, including their associated CPT/HCPCS codes and standard charges. Best practices for maintenance include: (1) Annual review and update of all CPT and HCPCS codes for additions, deletions, and revisions; (2) Setting charges at 200-300% of Medicare rates to avoid leaving money on the table with commercial payers; (3) Ensuring code-charge consistency; (4) Removing deleted codes; (5) Adding new services promptly; (6) Benchmarking against regional and national data.
Major medical coding certifications include: AAPC certifications — CPC (Certified Professional Coder), CPC-A (Apprentice), COC (Certified Outpatient Coder), CIC (Certified Inpatient Coder), and specialty-specific credentials (CIRCC, CPMA, CEMC, etc.). AHIMA certifications — CCS (Certified Coding Specialist), CCS-P (Certified Coding Specialist-Physician-based), CCA (Certified Coding Associate), and RHIT/RHIA for health information management. Most employers require at least one recognized certification, with CPC and CCS being the most widely sought.
A charge master (also called a charge description master or CDM) is a comprehensive listing of all billable items and services offered by a healthcare provider, including their associated CPT/HCPCS codes and standard charges. Best practices for maintenance include: (1) Annual review and update of all CPT and HCPCS codes for additions, deletions, and revisions; (2) Setting charges at 200-300% of Medicare rates to avoid leaving money on the table with commercial payers; (3) Ensuring code-charge consistency; (4) Removing deleted codes; (5) Adding new services promptly; (6) Benchmarking against regional and national data.
Major medical coding certifications include: AAPC certifications — CPC (Certified Professional Coder), CPC-A (Apprentice), COC (Certified Outpatient Coder), CIC (Certified Inpatient Coder), and specialty-specific credentials (CIRCC, CPMA, CEMC, etc.). AHIMA certifications — CCS (Certified Coding Specialist), CCS-P (Certified Coding Specialist-Physician-based), CCA (Certified Coding Associate), and RHIT/RHIA for health information management. Most employers require at least one recognized certification, with CPC and CCS being the most widely sought.
Medical coding involves translating healthcare diagnoses, procedures, and services into standardized alphanumeric codes (CPT, ICD-10, HCPCS). Medical billing uses those codes to create and submit claims to insurance companies and manage the reimbursement process. Coders focus on accuracy of code assignment based on clinical documentation, while billers focus on claim submission, follow-up, payment posting, and denial management. Both roles are essential to the revenue cycle.
Medical coding involves translating healthcare diagnoses, procedures, and services into standardized alphanumeric codes (CPT, ICD-10, HCPCS). Medical billing uses those codes to create and submit claims to insurance companies and manage the reimbursement process. Coders focus on accuracy of code assignment based on clinical documentation, while billers focus on claim submission, follow-up, payment posting, and denial management. Both roles are essential to the revenue cycle.
A claim rejection occurs before processing — the claim is returned because it contains invalid or missing information and cannot enter the adjudication process. Common reasons include invalid member ID, missing NPI, or formatting errors. Rejected claims can be corrected and resubmitted without an appeal. A claim denial occurs after the payer has processed and adjudicated the claim but determined it is not payable. Denials require investigation, may need an appeal, and are subject to timely filing limits for resubmission. Tracking both separately helps identify different process improvements.
A claim rejection occurs before processing — the claim is returned because it contains invalid or missing information and cannot enter the adjudication process. Common reasons include invalid member ID, missing NPI, or formatting errors. Rejected claims can be corrected and resubmitted without an appeal. A claim denial occurs after the payer has processed and adjudicated the claim but determined it is not payable. Denials require investigation, may need an appeal, and are subject to timely filing limits for resubmission. Tracking both separately helps identify different process improvements.
The No Surprises Act (effective January 2022) protects patients from unexpected out-of-network charges in certain scenarios: (1) Emergency services at out-of-network facilities must be billed at in-network rates; (2) Out-of-network providers at in-network facilities cannot balance bill patients without prior notice and consent; (3) Good faith estimates must be provided to uninsured/self-pay patients; (4) An independent dispute resolution (IDR) process resolves payment disputes between providers and payers. Practices must provide notice and consent forms when applicable and implement good faith estimate processes.
The No Surprises Act (effective January 2022) protects patients from unexpected out-of-network charges in certain scenarios: (1) Emergency services at out-of-network facilities must be billed at in-network rates; (2) Out-of-network providers at in-network facilities cannot balance bill patients without prior notice and consent; (3) Good faith estimates must be provided to uninsured/self-pay patients; (4) An independent dispute resolution (IDR) process resolves payment disputes between providers and payers. Practices must provide notice and consent forms when applicable and implement good faith estimate processes.
The CMS-1500 (previously HCFA-1500) is the standard claim form used by non-institutional providers for billing professional services to Medicare, Medicaid, and most commercial payers. The form contains 33 fields covering patient information, provider information, diagnosis codes, procedure codes, and charges. The UB-04 (CMS-1450) form is used by institutional providers (hospitals, skilled nursing facilities). Electronic claims use the ANSI X12 837P format (professional) or 837I format (institutional), which contain the same data elements as the paper forms.
Credentialing is the process of verifying a healthcare provider's qualifications to participate in insurance networks. Without active credentials, claims submitted under that provider will be denied. The credentialing process includes: (1) Completing CAQH ProView profile, (2) Submitting applications to individual payers, (3) Providing verification of education, licensure, DEA registration, malpractice insurance, and board certification, (4) Passing background checks. The process typically takes 90-180 days, and re-credentialing occurs every 2-3 years. Backdating of effective dates is not always possible, so starting early is critical.
The CMS-1500 (previously HCFA-1500) is the standard claim form used by non-institutional providers for billing professional services to Medicare, Medicaid, and most commercial payers. The form contains 33 fields covering patient information, provider information, diagnosis codes, procedure codes, and charges. The UB-04 (CMS-1450) form is used by institutional providers (hospitals, skilled nursing facilities). Electronic claims use the ANSI X12 837P format (professional) or 837I format (institutional), which contain the same data elements as the paper forms.
Credentialing is the process of verifying a healthcare provider's qualifications to participate in insurance networks. Without active credentials, claims submitted under that provider will be denied. The credentialing process includes: (1) Completing CAQH ProView profile, (2) Submitting applications to individual payers, (3) Providing verification of education, licensure, DEA registration, malpractice insurance, and board certification, (4) Passing background checks. The process typically takes 90-180 days, and re-credentialing occurs every 2-3 years. Backdating of effective dates is not always possible, so starting early is critical.
Dermatology biopsies are coded using 11102 (tangential biopsy, first lesion) and +11103 (each additional lesion), 11104 (punch biopsy, first lesion) and +11105 (each additional), or 11106 (incisional biopsy, first lesion) and +11107 (each additional). Excisions are coded from the 11400-11646 range based on site (trunk, extremities, face) and size (including margins). When a biopsy leads to an excision on the same day, the biopsy is typically bundled unless done on a separate lesion. Pathology interpretation (88305) can be billed separately if the dermatologist performs their own interpretation.
Chronic Care Management (CCM) is billed using CPT 99490 (20 minutes of clinical staff time per calendar month), 99491 (30 minutes of physician/qualified healthcare professional time), and 99439 (each additional 20 minutes). Requirements include: (1) Patient must have two or more chronic conditions expected to last at least 12 months; (2) Written consent from the patient; (3) A comprehensive care plan; (4) 24/7 access for urgent needs; (5) Continuity of care with a designated practitioner. Only one practitioner can bill CCM per patient per month.
Key mental health CPT codes include: 90834 (individual psychotherapy, 45 minutes), 90837 (individual psychotherapy, 60 minutes), 90832 (individual psychotherapy, 30 minutes), 90847 (family psychotherapy with patient present), 90846 (family psychotherapy without patient present), 90853 (group psychotherapy), 90791 (psychiatric diagnostic evaluation), 90792 (psychiatric diagnostic evaluation with medical services), and add-on code 90833/90836/90838 for psychotherapy performed with E/M services. Telehealth sessions use the same codes with modifier -95 or place of service 10.
CDT (Current Dental Terminology) codes are maintained by the American Dental Association and are used exclusively for dental procedures. They follow a D-prefix format (e.g., D0120 for periodic oral evaluation). CPT codes are maintained by the AMA and cover medical procedures. Some dental procedures may be billable to medical insurance using CPT codes, particularly oral surgery, TMJ treatment, and trauma-related dental services. Medical-dental cross-coding can maximize reimbursement when procedures have both dental and medical applications.
Well-child visits use preventive medicine CPT codes: 99381-99385 (new patient by age) and 99391-99395 (established patient by age). Immunizations require two components: the vaccine product code (90460-90461 for counseling-based, or 90471-90474 for administration) and the specific vaccine code (e.g., 90707 for MMR, 90686 for influenza). If a significant, separately identifiable problem is addressed during a well visit, an E/M code with modifier -25 can be added. The Vaccines for Children (VFC) program affects billing for government-insured patients.
Chronic Care Management (CCM) is billed using CPT 99490 (20 minutes of clinical staff time per calendar month), 99491 (30 minutes of physician/qualified healthcare professional time), and 99439 (each additional 20 minutes). Requirements include: (1) Patient must have two or more chronic conditions expected to last at least 12 months; (2) Written consent from the patient; (3) A comprehensive care plan; (4) 24/7 access for urgent needs; (5) Continuity of care with a designated practitioner. Only one practitioner can bill CCM per patient per month.
The most commonly billed cardiology CPT codes include: 93000 (Electrocardiogram with interpretation), 93306 (Transthoracic echocardiography), 93350 (Stress echocardiography), 93458 (Left heart catheterization), 93010 (ECG interpretation only), 93880 (Duplex scan of extracranial arteries), 93798 (Cardiac rehabilitation), and E/M codes 99213-99215 for office visits. Cardiology practices should also be familiar with modifier usage for technical (-TC) and professional (-26) components of diagnostic studies.
The most commonly billed cardiology CPT codes include: 93000 (Electrocardiogram with interpretation), 93306 (Transthoracic echocardiography), 93350 (Stress echocardiography), 93458 (Left heart catheterization), 93010 (ECG interpretation only), 93880 (Duplex scan of extracranial arteries), 93798 (Cardiac rehabilitation), and E/M codes 99213-99215 for office visits. Cardiology practices should also be familiar with modifier usage for technical (-TC) and professional (-26) components of diagnostic studies.
Most orthopedic surgical procedures include a global surgical period (typically 90 days for major surgeries, 10 days for minor surgeries). During this period, routine post-operative care is included in the surgical fee and should not be billed separately. However, services for unrelated conditions, complications requiring a return to the operating room, and diagnostic services unrelated to the surgery can be billed with appropriate modifiers (-24 for unrelated E/M, -78 for return to OR for related complication, -79 for unrelated procedure).
Most orthopedic surgical procedures include a global surgical period (typically 90 days for major surgeries, 10 days for minor surgeries). During this period, routine post-operative care is included in the surgical fee and should not be billed separately. However, services for unrelated conditions, complications requiring a return to the operating room, and diagnostic services unrelated to the surgery can be billed with appropriate modifiers (-24 for unrelated E/M, -78 for return to OR for related complication, -79 for unrelated procedure).
Dermatology biopsies are coded using 11102 (tangential biopsy, first lesion) and +11103 (each additional lesion), 11104 (punch biopsy, first lesion) and +11105 (each additional), or 11106 (incisional biopsy, first lesion) and +11107 (each additional). Excisions are coded from the 11400-11646 range based on site (trunk, extremities, face) and size (including margins). When a biopsy leads to an excision on the same day, the biopsy is typically bundled unless done on a separate lesion. Pathology interpretation (88305) can be billed separately if the dermatologist performs their own interpretation.
Key mental health CPT codes include: 90834 (individual psychotherapy, 45 minutes), 90837 (individual psychotherapy, 60 minutes), 90832 (individual psychotherapy, 30 minutes), 90847 (family psychotherapy with patient present), 90846 (family psychotherapy without patient present), 90853 (group psychotherapy), 90791 (psychiatric diagnostic evaluation), 90792 (psychiatric diagnostic evaluation with medical services), and add-on code 90833/90836/90838 for psychotherapy performed with E/M services. Telehealth sessions use the same codes with modifier -95 or place of service 10.
CDT (Current Dental Terminology) codes are maintained by the American Dental Association and are used exclusively for dental procedures. They follow a D-prefix format (e.g., D0120 for periodic oral evaluation). CPT codes are maintained by the AMA and cover medical procedures. Some dental procedures may be billable to medical insurance using CPT codes, particularly oral surgery, TMJ treatment, and trauma-related dental services. Medical-dental cross-coding can maximize reimbursement when procedures have both dental and medical applications.
Well-child visits use preventive medicine CPT codes: 99381-99385 (new patient by age) and 99391-99395 (established patient by age). Immunizations require two components: the vaccine product code (90460-90461 for counseling-based, or 90471-90474 for administration) and the specific vaccine code (e.g., 90707 for MMR, 90686 for influenza). If a significant, separately identifiable problem is addressed during a well visit, an E/M code with modifier -25 can be added. The Vaccines for Children (VFC) program affects billing for government-insured patients.
Telehealth billing in family medicine uses the same E/M codes (99202-99215) with place of service 10 (telehealth in patient's home) or POS 02 (telehealth facility). Add modifier -95 for synchronous telemedicine when required by payer. Key considerations: (1) Audio-visual technology must be used for most payers (some allow audio-only with modifier -93); (2) Verify payer-specific telehealth policies as coverage varies; (3) Document patient consent for telehealth; (4) Note patient location and ensure the patient is in an eligible state; (5) Check state licensure requirements; (6) Some payers reimburse at the same rate as in-person visits, while others may reduce rates.
Telehealth billing in family medicine uses the same E/M codes (99202-99215) with place of service 10 (telehealth in patient's home) or POS 02 (telehealth facility). Add modifier -95 for synchronous telemedicine when required by payer. Key considerations: (1) Audio-visual technology must be used for most payers (some allow audio-only with modifier -93); (2) Verify payer-specific telehealth policies as coverage varies; (3) Document patient consent for telehealth; (4) Note patient location and ensure the patient is in an eligible state; (5) Check state licensure requirements; (6) Some payers reimburse at the same rate as in-person visits, while others may reduce rates.
Dual dental coverage coordination follows specific rules: (1) Determine primary and secondary coverage using the birthday rule for dependents or subscriber-first rule; (2) Submit to the primary carrier first; (3) After receiving primary EOB, submit to secondary with the primary EOB attached; (4) The secondary payer typically covers remaining patient responsibility up to their allowed amount; (5) Total reimbursement cannot exceed 100% of the total fee; (6) Non-duplication of benefits clauses may limit secondary payment; (7) Some plans use a carve-out method vs. traditional COB; (8) Verify both plans' annual maximums are tracked separately.
Dual dental coverage coordination follows specific rules: (1) Determine primary and secondary coverage using the birthday rule for dependents or subscriber-first rule; (2) Submit to the primary carrier first; (3) After receiving primary EOB, submit to secondary with the primary EOB attached; (4) The secondary payer typically covers remaining patient responsibility up to their allowed amount; (5) Total reimbursement cannot exceed 100% of the total fee; (6) Non-duplication of benefits clauses may limit secondary payment; (7) Some plans use a carve-out method vs. traditional COB; (8) Verify both plans' annual maximums are tracked separately.
Psychological testing is billed using CPT 96130-96131 for test evaluation by the psychologist (96130 for the first hour, +96131 for each additional hour) and 96136-96139 for test administration. Neuropsychological testing uses 96132-96133 for evaluation (96132 first hour, +96133 additional) and the same administration codes. Key considerations: (1) Both face-to-face and non-face-to-face time count; (2) Technicians can administer under supervision using 96138-96139; (3) Prior authorization is often required; (4) Many payers limit annual testing hours; (5) Include diagnostic code supporting medical necessity (commonly F09, R41.3, or specific developmental/cognitive codes).
Psychological testing is billed using CPT 96130-96131 for test evaluation by the psychologist (96130 for the first hour, +96131 for each additional hour) and 96136-96139 for test administration. Neuropsychological testing uses 96132-96133 for evaluation (96132 first hour, +96133 additional) and the same administration codes. Key considerations: (1) Both face-to-face and non-face-to-face time count; (2) Technicians can administer under supervision using 96138-96139; (3) Prior authorization is often required; (4) Many payers limit annual testing hours; (5) Include diagnostic code supporting medical necessity (commonly F09, R41.3, or specific developmental/cognitive codes).
Major health insurance plan types include: (1) HMO (Health Maintenance Organization) — requires primary care physician referrals, limited to in-network providers; (2) PPO (Preferred Provider Organization) — more provider flexibility, higher out-of-network costs; (3) EPO (Exclusive Provider Organization) — no out-of-network coverage except emergencies; (4) POS (Point of Service) — hybrid of HMO and PPO; (5) HDHP (High Deductible Health Plan) — lower premiums, higher deductibles, often paired with HSA; (6) Medicare (Original A/B, Advantage Part C, Part D); (7) Medicaid — state-administered; (8) Workers' Compensation; (9) TRICARE for military.
Major health insurance plan types include: (1) HMO (Health Maintenance Organization) — requires primary care physician referrals, limited to in-network providers; (2) PPO (Preferred Provider Organization) — more provider flexibility, higher out-of-network costs; (3) EPO (Exclusive Provider Organization) — no out-of-network coverage except emergencies; (4) POS (Point of Service) — hybrid of HMO and PPO; (5) HDHP (High Deductible Health Plan) — lower premiums, higher deductibles, often paired with HSA; (6) Medicare (Original A/B, Advantage Part C, Part D); (7) Medicaid — state-administered; (8) Workers' Compensation; (9) TRICARE for military.
Most electronic claims are processed within 14-30 days, depending on the payer. Medicare requires payment within 30 days for electronic claims and 45 days for paper claims. Commercial payers vary but typically process clean claims within 15-45 days. Paper claims take significantly longer, often 45-60 days. Claims requiring manual review, additional documentation, or prior authorization verification may take longer. State prompt-pay laws may also set maximum timeframes for claim processing.
Most electronic claims are processed within 14-30 days, depending on the payer. Medicare requires payment within 30 days for electronic claims and 45 days for paper claims. Commercial payers vary but typically process clean claims within 15-45 days. Paper claims take significantly longer, often 45-60 days. Claims requiring manual review, additional documentation, or prior authorization verification may take longer. State prompt-pay laws may also set maximum timeframes for claim processing.
In-network providers have contracted rates with insurance companies, accept agreed-upon reimbursement, and patients typically pay lower cost-sharing. Out-of-network providers have no contract, can charge their full fee schedule, and patients face higher deductibles, coinsurance, and potential balance billing. Key differences: (1) In-network claims are processed at contracted rates; (2) Out-of-network claims may be processed at usual, customary, and reasonable (UCR) rates; (3) Balance billing is prohibited for in-network services but may be allowed out-of-network (subject to state laws and the No Surprises Act); (4) Prior authorization requirements may differ.
In-network providers have contracted rates with insurance companies, accept agreed-upon reimbursement, and patients typically pay lower cost-sharing. Out-of-network providers have no contract, can charge their full fee schedule, and patients face higher deductibles, coinsurance, and potential balance billing. Key differences: (1) In-network claims are processed at contracted rates; (2) Out-of-network claims may be processed at usual, customary, and reasonable (UCR) rates; (3) Balance billing is prohibited for in-network services but may be allowed out-of-network (subject to state laws and the No Surprises Act); (4) Prior authorization requirements may differ.
Most dental insurance plans have an annual maximum benefit, typically ranging from $1,000-$2,500 per person per year. Once the maximum is reached, the patient is responsible for 100% of remaining costs. Plans typically cover preventive services at 100%, basic services (fillings, extractions) at 80%, and major services (crowns, bridges) at 50%. Many plans also have a deductible ($25-$100) that must be met before benefits apply to basic and major services. Orthodontic benefits often have a separate lifetime maximum.
Most dental insurance plans have an annual maximum benefit, typically ranging from $1,000-$2,500 per person per year. Once the maximum is reached, the patient is responsible for 100% of remaining costs. Plans typically cover preventive services at 100%, basic services (fillings, extractions) at 80%, and major services (crowns, bridges) at 50%. Many plans also have a deductible ($25-$100) that must be met before benefits apply to basic and major services. Orthodontic benefits often have a separate lifetime maximum.
Medicaid pediatric billing involves several unique considerations: (1) Reimbursement rates are generally lower than Medicare and commercial rates; (2) EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) provides comprehensive preventive services for children under 21; (3) Vaccines may be covered under the Vaccines for Children (VFC) program, with only administration fees billable; (4) State-specific Medicaid managed care plans have varying rules; (5) Timely filing limits are typically 90-365 days depending on the state; (6) Some states require specific modifiers or procedure codes; (7) Prior authorization requirements vary by state plan.
Common dermatology procedures requiring prior authorization include: Mohs micrographic surgery (especially for non-facial lesions), biologic medications for psoriasis (adalimumab, secukinumab, etc.), phototherapy (UVB, PUVA), cosmetic procedures when claimed as medically necessary, allergy testing, advanced wound care treatments, and certain injectable medications. Requirements vary significantly by payer, so it's essential to verify authorization requirements for each patient's specific plan before performing services.
Common orthopedic procedures requiring prior authorization include: (1) MRI, CT scans, and advanced imaging; (2) Joint replacement surgeries (hip, knee, shoulder); (3) Arthroscopic procedures; (4) Spinal surgeries (fusion, decompression, disc replacement); (5) DME such as braces, orthotics, and wheelchairs; (6) Physical therapy beyond initial visits; (7) Injections (joint, epidural steroid, viscosupplementation); (8) Outpatient vs. inpatient status for surgical procedures. Authorization requirements vary by payer and plan, so always verify before scheduling procedures.
Medicaid pediatric billing involves several unique considerations: (1) Reimbursement rates are generally lower than Medicare and commercial rates; (2) EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) provides comprehensive preventive services for children under 21; (3) Vaccines may be covered under the Vaccines for Children (VFC) program, with only administration fees billable; (4) State-specific Medicaid managed care plans have varying rules; (5) Timely filing limits are typically 90-365 days depending on the state; (6) Some states require specific modifiers or procedure codes; (7) Prior authorization requirements vary by state plan.
Common dermatology procedures requiring prior authorization include: Mohs micrographic surgery (especially for non-facial lesions), biologic medications for psoriasis (adalimumab, secukinumab, etc.), phototherapy (UVB, PUVA), cosmetic procedures when claimed as medically necessary, allergy testing, advanced wound care treatments, and certain injectable medications. Requirements vary significantly by payer, so it's essential to verify authorization requirements for each patient's specific plan before performing services.
Common orthopedic procedures requiring prior authorization include: (1) MRI, CT scans, and advanced imaging; (2) Joint replacement surgeries (hip, knee, shoulder); (3) Arthroscopic procedures; (4) Spinal surgeries (fusion, decompression, disc replacement); (5) DME such as braces, orthotics, and wheelchairs; (6) Physical therapy beyond initial visits; (7) Injections (joint, epidural steroid, viscosupplementation); (8) Outpatient vs. inpatient status for surgical procedures. Authorization requirements vary by payer and plan, so always verify before scheduling procedures.
Value-based reimbursement shifts payment from volume to quality outcomes. Family medicine practices are affected through: (1) MIPS/MACRA reporting requirements that adjust Medicare payments +/- 9%; (2) Accountable Care Organizations (ACOs) that share savings/losses; (3) Pay-for-performance programs from commercial payers; (4) Quality measures including preventive care rates, chronic disease management, and patient satisfaction. Practices should invest in care management infrastructure, quality reporting systems, and patient engagement tools to maximize value-based reimbursement.
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that insurance plans offering mental health benefits must provide coverage that is no more restrictive than coverage for medical/surgical conditions. This applies to financial requirements (deductibles, copays), treatment limitations (visit limits, prior authorization), and non-quantitative treatment limitations (fail-first requirements, network adequacy). Billing practices should track and challenge any payer denials that appear to violate parity requirements.
Value-based reimbursement shifts payment from volume to quality outcomes. Family medicine practices are affected through: (1) MIPS/MACRA reporting requirements that adjust Medicare payments +/- 9%; (2) Accountable Care Organizations (ACOs) that share savings/losses; (3) Pay-for-performance programs from commercial payers; (4) Quality measures including preventive care rates, chronic disease management, and patient satisfaction. Practices should invest in care management infrastructure, quality reporting systems, and patient engagement tools to maximize value-based reimbursement.
Cardiac device implantation billing requires coding for both the procedure and the device: (1) Pacemaker insertion — 33206-33208 based on lead placement; (2) ICD implantation — 33249; (3) CRT-D — 33224-33225 for lead placement plus 33249 for generator; (4) Device replacement — 33227-33229 for pacemaker, 33262-33264 for ICD; (5) Lead revision/extraction — 33233-33244. The device itself is coded separately using HCPCS C-codes in the outpatient setting. Hospital facility fees and professional fees are billed separately. Verify payer-specific requirements for device registration and prior authorization.
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that insurance plans offering mental health benefits must provide coverage that is no more restrictive than coverage for medical/surgical conditions. This applies to financial requirements (deductibles, copays), treatment limitations (visit limits, prior authorization), and non-quantitative treatment limitations (fail-first requirements, network adequacy). Billing practices should track and challenge any payer denials that appear to violate parity requirements.
Cardiac device implantation billing requires coding for both the procedure and the device: (1) Pacemaker insertion — 33206-33208 based on lead placement; (2) ICD implantation — 33249; (3) CRT-D — 33224-33225 for lead placement plus 33249 for generator; (4) Device replacement — 33227-33229 for pacemaker, 33262-33264 for ICD; (5) Lead revision/extraction — 33233-33244. The device itself is coded separately using HCPCS C-codes in the outpatient setting. Hospital facility fees and professional fees are billed separately. Verify payer-specific requirements for device registration and prior authorization.
Under current guidelines, E/M level is determined by either Medical Decision Making (MDM) or total time. For MDM-based selection: (1) Evaluate the number and complexity of problems addressed (minimal, low, moderate, high); (2) Assess data reviewed — ordering/reviewing tests, independent interpretation, discussion with external physician; (3) Determine risk — including risk of morbidity, drug therapy management, and decisions about hospitalization. Two of three MDM elements must meet or exceed the level. For time-based selection, count all physician time on the date of encounter including documentation, care coordination, and counseling. E/M 99213 requires low MDM, 99214 moderate, 99215 high.
Under current guidelines, E/M level is determined by either Medical Decision Making (MDM) or total time. For MDM-based selection: (1) Evaluate the number and complexity of problems addressed (minimal, low, moderate, high); (2) Assess data reviewed — ordering/reviewing tests, independent interpretation, discussion with external physician; (3) Determine risk — including risk of morbidity, drug therapy management, and decisions about hospitalization. Two of three MDM elements must meet or exceed the level. For time-based selection, count all physician time on the date of encounter including documentation, care coordination, and counseling. E/M 99213 requires low MDM, 99214 moderate, 99215 high.
The current E/M coding guidelines (effective since 2023 for all E/M categories) base code selection on Medical Decision Making (MDM) or total time. MDM has three components: (1) Number and complexity of problems addressed, (2) Amount and complexity of data to be reviewed and analyzed, (3) Risk of complications, morbidity, or mortality. Two of three MDM elements must meet or exceed the requirements for a given level. Time-based coding counts the total time on the date of the encounter, including face-to-face and non-face-to-face activities like documentation, care coordination, and order review.
The current E/M coding guidelines (effective since 2023 for all E/M categories) base code selection on Medical Decision Making (MDM) or total time. MDM has three components: (1) Number and complexity of problems addressed, (2) Amount and complexity of data to be reviewed and analyzed, (3) Risk of complications, morbidity, or mortality. Two of three MDM elements must meet or exceed the requirements for a given level. Time-based coding counts the total time on the date of the encounter, including face-to-face and non-face-to-face activities like documentation, care coordination, and order review.
HCPCS Level II codes are alphanumeric codes (beginning with letters A-V) that identify products, supplies, and services not covered by CPT codes. They are used for: (1) Durable medical equipment (DME) — E codes (e.g., E0114 for crutches); (2) Injectable drugs — J codes (e.g., J1745 for infliximab); (3) Ambulance services — A codes; (4) Orthotics and prosthetics — L codes; (5) Temporary codes — G codes for CMS-specific services; (6) Vision/hearing services — V codes. HCPCS codes are required for Medicare and Medicaid billing and are increasingly used by commercial payers.
HCPCS Level II codes are alphanumeric codes (beginning with letters A-V) that identify products, supplies, and services not covered by CPT codes. They are used for: (1) Durable medical equipment (DME) — E codes (e.g., E0114 for crutches); (2) Injectable drugs — J codes (e.g., J1745 for infliximab); (3) Ambulance services — A codes; (4) Orthotics and prosthetics — L codes; (5) Temporary codes — G codes for CMS-specific services; (6) Vision/hearing services — V codes. HCPCS codes are required for Medicare and Medicaid billing and are increasingly used by commercial payers.
Modifier -25 should be used when a significant, separately identifiable E/M service is performed on the same day as a minor procedure or other service. The E/M service must be above and beyond the usual pre-operative and post-operative care associated with the procedure. Common family medicine scenarios include: performing a skin biopsy during an office visit for an unrelated complaint, administering injections during a visit for a separate medical condition, or addressing a new problem during a visit primarily for a procedure. Documentation must clearly support both services.
Key orthopedic modifiers include: -LT/-RT (left/right side), -50 (bilateral procedure), -59 (distinct procedural service), -25 (significant separate E/M service), -57 (decision for surgery), -78 (return to OR for complication), -79 (unrelated procedure during post-op period), -76 (repeat procedure by same physician), -22 (increased procedural service), and -62 (two surgeons). Laterality modifiers are especially critical in orthopedics to prevent claim denials and ensure accurate documentation.
Cardiac catheterization coding requires careful attention to the type of catheterization (left heart, right heart, or combined), whether coronary angiography was performed, and whether any interventions were done. CPT 93451 is used for right heart catheterization, 93452 for left heart catheterization with ventriculography, 93453 for combined right and left. If percutaneous coronary intervention (PCI) is performed, additional codes from the 92920-92944 range apply. Always code injection procedures and imaging supervision separately when appropriate.
Pediatric E/M coding has several age-specific considerations: (1) Newborn care uses codes 99460-99463 for initial and subsequent hospital care; (2) Neonatal critical care uses 99468-99469 for initial and 99471-99472 for subsequent days; (3) Pediatric critical care uses 99475-99476; (4) Well-child visits have age-specific codes (infant, 1-4, 5-11, 12-17); (5) Developmental screening (96110) and depression screening (96127) are commonly added to preventive visits. Time-based coding may be particularly relevant for complex pediatric cases with parent counseling.
Key orthopedic modifiers include: -LT/-RT (left/right side), -50 (bilateral procedure), -59 (distinct procedural service), -25 (significant separate E/M service), -57 (decision for surgery), -78 (return to OR for complication), -79 (unrelated procedure during post-op period), -76 (repeat procedure by same physician), -22 (increased procedural service), and -62 (two surgeons). Laterality modifiers are especially critical in orthopedics to prevent claim denials and ensure accurate documentation.
Cardiac catheterization coding requires careful attention to the type of catheterization (left heart, right heart, or combined), whether coronary angiography was performed, and whether any interventions were done. CPT 93451 is used for right heart catheterization, 93452 for left heart catheterization with ventriculography, 93453 for combined right and left. If percutaneous coronary intervention (PCI) is performed, additional codes from the 92920-92944 range apply. Always code injection procedures and imaging supervision separately when appropriate.
Pediatric E/M coding has several age-specific considerations: (1) Newborn care uses codes 99460-99463 for initial and subsequent hospital care; (2) Neonatal critical care uses 99468-99469 for initial and 99471-99472 for subsequent days; (3) Pediatric critical care uses 99475-99476; (4) Well-child visits have age-specific codes (infant, 1-4, 5-11, 12-17); (5) Developmental screening (96110) and depression screening (96127) are commonly added to preventive visits. Time-based coding may be particularly relevant for complex pediatric cases with parent counseling.
Modifier -25 should be used when a significant, separately identifiable E/M service is performed on the same day as a minor procedure or other service. The E/M service must be above and beyond the usual pre-operative and post-operative care associated with the procedure. Common family medicine scenarios include: performing a skin biopsy during an office visit for an unrelated complaint, administering injections during a visit for a separate medical condition, or addressing a new problem during a visit primarily for a procedure. Documentation must clearly support both services.
Dental implant coding involves multiple phases: (1) Surgical placement - D6010 (endosteal implant), D6040 (eposteal implant); (2) Abutment - D6056 (prefabricated abutment), D6057 (custom abutment); (3) Crown - D6058 (abutment-supported porcelain/ceramic crown), D6059 (abutment-supported PFM crown), D6060 (abutment-supported metal crown); (4) Additional procedures may include D6104 (bone graft for implant), D7953 (bone graft, autogenous), and D4266 (guided tissue regeneration). Each phase should be billed on the date the specific service is performed.
Dental implant coding involves multiple phases: (1) Surgical placement - D6010 (endosteal implant), D6040 (eposteal implant); (2) Abutment - D6056 (prefabricated abutment), D6057 (custom abutment); (3) Crown - D6058 (abutment-supported porcelain/ceramic crown), D6059 (abutment-supported PFM crown), D6060 (abutment-supported metal crown); (4) Additional procedures may include D6104 (bone graft for implant), D7953 (bone graft, autogenous), and D4266 (guided tissue regeneration). Each phase should be billed on the date the specific service is performed.
Mohs surgery uses CPT codes 17311 (first stage, up to 5 tissue blocks, head/neck/hands/feet/genitalia), 17312 (each additional stage, same criteria), 17313 (first stage, trunk/extremities), and 17314 (each additional stage, same criteria). The surgeon also codes the wound repair/closure separately using appropriate repair codes (12001-13160 for simple/intermediate/complex repairs, 14000-14350 for adjacent tissue transfer, or 15100-15278 for grafts). Modifier -59 may be needed for multiple lesion sites. Pathology interpretation is included in the Mohs codes.
Fracture care coding depends on the treatment approach: (1) Closed treatment without manipulation — 2XXXX codes specific to anatomical site; (2) Closed treatment with manipulation — higher-valued codes for the same site; (3) Open treatment (ORIF) — surgical codes with 90-day global periods. Initial casting/splinting is included in the fracture care code. Subsequent cast changes use 29000-29799 series. Follow-up visits during the global period are included unless a separate problem is addressed (modifier -24). Multiple fractures are coded individually. X-ray interpretation (7XXXX codes) is billed separately with modifier -26 for the professional component.
Fracture care coding depends on the treatment approach: (1) Closed treatment without manipulation — 2XXXX codes specific to anatomical site; (2) Closed treatment with manipulation — higher-valued codes for the same site; (3) Open treatment (ORIF) — surgical codes with 90-day global periods. Initial casting/splinting is included in the fracture care code. Subsequent cast changes use 29000-29799 series. Follow-up visits during the global period are included unless a separate problem is addressed (modifier -24). Multiple fractures are coded individually. X-ray interpretation (7XXXX codes) is billed separately with modifier -26 for the professional component.
Mohs surgery uses CPT codes 17311 (first stage, up to 5 tissue blocks, head/neck/hands/feet/genitalia), 17312 (each additional stage, same criteria), 17313 (first stage, trunk/extremities), and 17314 (each additional stage, same criteria). The surgeon also codes the wound repair/closure separately using appropriate repair codes (12001-13160 for simple/intermediate/complex repairs, 14000-14350 for adjacent tissue transfer, or 15100-15278 for grafts). Modifier -59 may be needed for multiple lesion sites. Pathology interpretation is included in the Mohs codes.
The most common claim denial reasons include: (1) Missing or invalid patient information, (2) Incorrect or mismatched CPT/ICD-10 codes, (3) Lack of prior authorization, (4) Duplicate claim submission, (5) Timely filing limit exceeded, (6) Non-covered services, (7) Coordination of benefits issues, (8) Incorrect provider information or NPI, (9) Medical necessity not established, and (10) Bundling/unbundling errors. Most denials are preventable with proper front-end processes and claim scrubbing.
The most common claim denial reasons include: (1) Missing or invalid patient information, (2) Incorrect or mismatched CPT/ICD-10 codes, (3) Lack of prior authorization, (4) Duplicate claim submission, (5) Timely filing limit exceeded, (6) Non-covered services, (7) Coordination of benefits issues, (8) Incorrect provider information or NPI, (9) Medical necessity not established, and (10) Bundling/unbundling errors. Most denials are preventable with proper front-end processes and claim scrubbing.
Consequences of billing fraud include: (1) Civil penalties under the False Claims Act — up to $11,000 per false claim plus treble damages; (2) Criminal penalties — fines up to $250,000 and imprisonment up to 10 years; (3) Exclusion from Medicare, Medicaid, and other federal healthcare programs; (4) Loss of medical licensure; (5) Corporate Integrity Agreements (CIAs) requiring ongoing compliance monitoring; (6) Whistleblower lawsuits under qui tam provisions; (7) Reputational damage. Even unintentional billing errors can trigger audits and recoupment if they form a pattern.
A coding audit is a systematic review of medical records and claims to evaluate coding accuracy, documentation adequacy, and compliance with regulations. Types include: (1) Prospective audits — review before claim submission; (2) Retrospective audits — review after claim submission; (3) Targeted audits — focus on specific codes or providers; (4) Random sample audits — statistically representative review. Best practices recommend: quarterly internal audits of at least 10-20 charts per provider, annual external audits, and targeted audits when trends suggest potential issues. Audit accuracy targets should be 95% or higher.
Consequences of billing fraud include: (1) Civil penalties under the False Claims Act — up to $11,000 per false claim plus treble damages; (2) Criminal penalties — fines up to $250,000 and imprisonment up to 10 years; (3) Exclusion from Medicare, Medicaid, and other federal healthcare programs; (4) Loss of medical licensure; (5) Corporate Integrity Agreements (CIAs) requiring ongoing compliance monitoring; (6) Whistleblower lawsuits under qui tam provisions; (7) Reputational damage. Even unintentional billing errors can trigger audits and recoupment if they form a pattern.
A coding audit is a systematic review of medical records and claims to evaluate coding accuracy, documentation adequacy, and compliance with regulations. Types include: (1) Prospective audits — review before claim submission; (2) Retrospective audits — review after claim submission; (3) Targeted audits — focus on specific codes or providers; (4) Random sample audits — statistically representative review. Best practices recommend: quarterly internal audits of at least 10-20 charts per provider, annual external audits, and targeted audits when trends suggest potential issues. Audit accuracy targets should be 95% or higher.
The Physician Self-Referral Law (Stark Law) prohibits physicians from referring Medicare/Medicaid patients for designated health services (DHS) to entities with which they or their immediate family members have a financial relationship, unless an exception applies. DHS includes clinical laboratory services, physical therapy, radiology, DME, and more. Violations result in: denial of payment, refund obligations, civil monetary penalties up to $15,000 per service, treble damages, and program exclusion. Common exceptions include the in-office ancillary services exception, fair market value compensation, and bona fide employment arrangements.
The Physician Self-Referral Law (Stark Law) prohibits physicians from referring Medicare/Medicaid patients for designated health services (DHS) to entities with which they or their immediate family members have a financial relationship, unless an exception applies. DHS includes clinical laboratory services, physical therapy, radiology, DME, and more. Violations result in: denial of payment, refund obligations, civil monetary penalties up to $15,000 per service, treble damages, and program exclusion. Common exceptions include the in-office ancillary services exception, fair market value compensation, and bona fide employment arrangements.
Cardiology E/M documentation must support the level of medical decision-making (MDM) billed. For 2024+ guidelines, documentation should clearly reflect: (1) Number and complexity of problems addressed, (2) Amount and complexity of data reviewed (including review of prior cardiac studies, external records, and test ordering), (3) Risk of complications and management decisions. Cardiology-specific documentation should include cardiac history, current medications, relevant test results, assessment of cardiac conditions, and the treatment plan.
Cardiology E/M documentation must support the level of medical decision-making (MDM) billed. For 2024+ guidelines, documentation should clearly reflect: (1) Number and complexity of problems addressed, (2) Amount and complexity of data reviewed (including review of prior cardiac studies, external records, and test ordering), (3) Risk of complications and management decisions. Cardiology-specific documentation should include cardiac history, current medications, relevant test results, assessment of cardiac conditions, and the treatment plan.
Developmental screening billing requirements include: (1) Use CPT 96110 for developmental screening with a standardized instrument (e.g., ASQ-3, PEDS, M-CHAT); (2) The screening tool must be a validated, standardized instrument with published reliability data; (3) Document the specific screening tool used, the results, and any follow-up actions; (4) AAP recommends developmental screening at 9, 18, and 30 months; (5) Autism-specific screening is recommended at 18 and 24 months using M-CHAT-R/F; (6) Bill 96127 for emotional/behavioral assessment (e.g., PHQ-A for adolescent depression); (7) Modifier -25 may be needed if billed with a preventive visit; (8) Most payers cover age-appropriate screenings as preventive services.
Mental health documentation must include: (1) Patient identifying information and diagnosis, (2) Start and stop time of the session, (3) Type of therapy provided, (4) Issues discussed and interventions used, (5) Patient's response to treatment, (6) Treatment plan updates, (7) Risk assessment when applicable, and (8) Medical necessity for continued treatment. For psychiatric E/M services billed with add-on psychotherapy codes, both the E/M and psychotherapy components must be separately documented.
Mental health documentation must include: (1) Patient identifying information and diagnosis, (2) Start and stop time of the session, (3) Type of therapy provided, (4) Issues discussed and interventions used, (5) Patient's response to treatment, (6) Treatment plan updates, (7) Risk assessment when applicable, and (8) Medical necessity for continued treatment. For psychiatric E/M services billed with add-on psychotherapy codes, both the E/M and psychotherapy components must be separately documented.
Distinguishing cosmetic from medical procedures is critical for billing compliance: (1) Medical procedures require documentation of medical necessity including diagnosis, symptoms, functional impairment, and failed conservative treatments; (2) Cosmetic procedures are not covered by insurance and must be billed directly to the patient; (3) Some procedures can be either medical or cosmetic (e.g., blepharoplasty for visual field obstruction vs. aesthetics); (4) Documentation must clearly support the medical indication with clinical findings, photographs, and test results where applicable; (5) Mixing cosmetic and medical billing in the same encounter requires careful separation of charges.
Medical billing services are typically priced using one of three models: (1) Percentage of collections, ranging from 4-10% of collected revenue depending on practice size and specialty; (2) Per-claim fee, typically $4-$10 per claim; (3) Flat monthly fee, ranging from $1,000-$5,000+ based on volume. Factors affecting cost include specialty complexity, claim volume, number of providers, payer mix, and additional services like credentialing or prior authorization management.
Medical billing services are typically priced using one of three models: (1) Percentage of collections, ranging from 4-10% of collected revenue depending on practice size and specialty; (2) Per-claim fee, typically $4-$10 per claim; (3) Flat monthly fee, ranging from $1,000-$5,000+ based on volume. Factors affecting cost include specialty complexity, claim volume, number of providers, payer mix, and additional services like credentialing or prior authorization management.
Essential medical billing KPIs include: (1) Clean claim rate — target 95%+; (2) Days in accounts receivable (DAR) — target under 35 days; (3) First pass resolution rate — target 90%+; (4) Denial rate — target under 5%; (5) Collection rate — target 95%+ of allowed amounts; (6) Net collection rate — total payments divided by allowed amounts; (7) Cost to collect — percentage of revenue spent on billing operations; (8) Claim rejection rate — target under 4%; (9) Patient collection rate; (10) Accounts receivable over 120 days — target under 12% of total A/R.
Essential medical billing KPIs include: (1) Clean claim rate — target 95%+; (2) Days in accounts receivable (DAR) — target under 35 days; (3) First pass resolution rate — target 90%+; (4) Denial rate — target under 5%; (5) Collection rate — target 95%+ of allowed amounts; (6) Net collection rate — total payments divided by allowed amounts; (7) Cost to collect — percentage of revenue spent on billing operations; (8) Claim rejection rate — target under 4%; (9) Patient collection rate; (10) Accounts receivable over 120 days — target under 12% of total A/R.