Medical Billing, Coding & RCM FAQs

Our billing fee is a percentage of the payments we collect for you, so it rises and falls with your actual collections rather than your charges. The rate depends on your specialty, claim volume, payer mix and which services are included. We quote it in writing after a short review of your practice.

The written quote lists every service included — typically claim preparation and submission, rejection and denial work, payment posting, follow-up, patient statements and monthly reporting — and anything priced separately, such as credentialing or a project to work old A/R. Nothing outside the quote is charged without your written agreement.

Setup work such as system access, payer setup for electronic remittances and workflow mapping is described in the quote. If any part of it carries a separate charge, the quote says so before you sign. One-off projects, such as a large backlog of old claims, are scoped and priced separately and only if you want them.

Yes, if you want us to. Claims from before the start date are reviewed by filing deadline and value, and we agree in writing how that work is priced — either within the standard fee or as a separate project — before we begin.

It depends on specialty, volume, payer mix and scope, so any fair comparison starts with your own figures. Add up the full cost of in-house billing — wages, benefits, cover for absences, training, software, clearinghouse and statement costs and management time — and compare it with a quoted fee applied to your actual net collections, checking what each quote leaves out.

The most common model is a percentage of collections. Others charge per claim, a flat monthly fee or a combination. Whatever the model, check whether the fee applies to all payments or only insurance payments, whether there is a minimum or setup fee, and which costs — clearinghouse, statements, postage, credentialing — are passed through separately.

Set a start date and record a baseline of A/R, denials and collections. New claims move to the new process from that date, while claims already submitted are either finished by the previous company or transferred with their history. Remittance and clearinghouse setup is updated in advance so payments keep flowing, and open claims are worked by filing deadline.

It should set a reasonable notice period, state any early termination fee, confirm that you own your data and reports, and explain what happens to claims submitted before the end date — whether the company keeps working them, for how long, and how fees on those collections are charged.

Size alone is not the deciding factor. Small practices often benefit most because billing tends to depend on one person. The more useful questions are whether claims keep moving when that person is away, whether old A/R is growing, and how much of the owner’s time billing takes.

We review a sample of your claims, remittances and A/R aging and give you a written summary of what we found: the most common denial reasons and where they start, claims at risk of missing deadlines, and the changes most likely to improve collections. It is yours to keep whether or not you work with us.

No. The assessment is free and there is no obligation to work with us afterward. The findings are yours to use with your own team or another billing company.

A full billing service usually covers charge entry or review, claim scrubbing and submission, clearinghouse rejection work, payment posting from remittances, denial management and appeals, follow-up on unpaid claims, patient statements and monthly reporting. Eligibility checks, coding, credentialing and prior authorization may be included or offered separately, so confirm the scope in writing.

You should not. Keep ownership of your data and direct access to your practice management system, receive monthly reports on the same measures you would track yourself, and have a regular review meeting. Your agreement should also say what happens to open claims and data if you end the relationship.

Yes. A common hybrid keeps registration, eligibility checks and copay collection with the front desk and outsources claims, posting, denials and follow-up. Others outsource only coding, credentialing, prior authorizations or a project to work old A/R. The key is a clear written split of who does what.

That is your decision. Many practices move billing staff to front-desk, eligibility, authorization or patient-balance work, where their knowledge of your patients and payers is valuable. A hybrid arrangement can keep some billing tasks in house.

It depends on what you prefer. Patient statements can list a billing phone number answered by the billing team, or your own front desk can take calls with support from the billing team for anything complex. Either way, the statement should be clear enough that fewer patients need to call.

Medical billing is the back-end work of creating claims, sending them, posting payments and following up. Revenue cycle management covers the whole process from scheduling to final payment, including registration, eligibility, authorization, documentation and coding, and it uses shared measures to fix problems where they start rather than where they show up.

Track days in A/R, the share of A/R over 90 days, the clean claim rate, the denial rate broken down by reason and payer, the net collection rate and charge lag (days from visit to claim). Calculate each one the same way every month, and compare it with your own history rather than with figures calculated differently.

Many denials start at registration: wrong subscriber details, coverage that has ended, a missing secondary plan or no authorization. These are cheap to fix before the visit and expensive afterward. Checking insurance cards, running eligibility before each visit and confirming authorizations prevents a large share of avoidable denials.

Yes, and for a group they should be. Charges, collections, charge lag, denials and A/R broken out by provider, location, specialty and payer show where a problem sits, which a practice-wide total hides. The breakdown depends on how providers and locations are set up in your practice management system.

Medical coding translates the provider’s documentation into standard codes — ICD-10-CM diagnoses and CPT or HCPCS procedures, with modifiers. Medical billing uses those codes to create claims, submits them, posts payments, works denials and collects patient balances. Small practices often combine the roles; larger ones usually separate them.

A clearinghouse sits between a practice and many payers. It checks claims for format and payer-specific errors, sends them to the right payer, returns acknowledgments showing whether each claim was accepted or rejected, and delivers electronic remittances. Many also offer eligibility and claim status checks.

A clean claim has all the information a payer needs to process it, with no errors, so it is accepted and adjudicated without being returned for correction. Medicare and many state prompt-pay laws also use the term for claims that must be paid within a set time once received.

Since 2021, office and outpatient visit levels (99202–99215) are chosen either by the level of medical decision making — the number and complexity of problems, the data reviewed and the risk of management — or by the clinician’s total time on the date of the visit. History and exam are documented as appropriate but no longer count toward the level.

A coding audit compares a sample of claims with the documentation behind them to check that codes, levels and modifiers are supported. Many practices review a sample at least once a year, and more often when a provider is new, codes change or a payer starts denying a service. Findings should lead to education, not only corrections.

The coder does not guess or upcode. If the note is unclear or incomplete, the coder sends the provider a query asking for clarification, worded so it does not lead toward a particular answer. If the documentation still does not support the code, the claim is coded to what is documented.

CPT codes change every January, ICD-10-CM codes every October (and occasionally April), HCPCS Level II codes and NCCI edits every quarter, and payer policies whenever the payer publishes them. Fee schedules, claim edits and coding habits need updating on the same schedule.

Add-on codes, such as those for additional coronary vessels or branches treated in the same session, are reported together with the primary procedure code and are never billed alone. Each additional vessel or branch is coded once, with the coronary modifier that identifies it, and only when the documentation describes the work in that vessel.

A generator change is coded with the replacement code for the system type — single, dual or multiple lead — which includes removing the old generator and inserting the new one. Removal without replacement is coded separately. Any new or repositioned leads, and upgrades from one system type to another, are coded according to what the operative report describes.

Modifier 25 is added to an E/M service performed on the same day as a minor procedure when the visit is significant and separately identifiable — for example, evaluating a new problem beyond the usual pre-procedure assessment. The note must show the separate work; routine evaluation before a procedure is included in the procedure.

Routine post-operative visits are included in the surgical payment. Other services can be billed with the right modifier: 24 for an unrelated visit, 58 for a staged or planned related procedure, 78 for a return to the operating room for a complication, and 79 for an unrelated procedure. The documentation must support the reason.

Workers’ compensation claims are paid by the employer’s carrier under state rules, usually with a state fee schedule, a carrier claim number and often required reports or forms. Authorization rules differ from health plans, and patients generally cannot be billed for covered work-injury care. Each claim is set up with the carrier, adjuster and claim number before the visit.

Only if the practice is enrolled with Medicare as a DMEPOS supplier and meets the supplier and accreditation standards. Those items are then billed to the DME Medicare Administrative Contractor, not the Part B contractor, with HCPCS codes, documentation of medical necessity and, for some items, a specific order. Commercial plans set their own rules.

The injection procedure is billed with the code for the joint size and whether ultrasound guidance was used, with laterality as the payer requires. The drug is billed separately with its HCPCS code, and units must match the code’s definition — for example, a code defined per 10 mg billed as four units for a 40 mg dose.

Usually because the screening became diagnostic or therapeutic — for example, a polyp was removed — and the plan applied cost-sharing. Medicare is phasing that coinsurance out by 2030; commercial plans follow their own rules. Correct use of modifier PT (Medicare) or 33 (commercial) and explaining the possibility to patients beforehand prevents most complaints.

For Medicare, yes: since 2023, a follow-on colonoscopy after a positive stool-based screening test is treated as part of the screening benefit. Many commercial plans now treat it the same way under federal preventive-services guidance, but the patient’s plan should be checked before the procedure.

If the scope cannot reach the cecum, the physician reports the colonoscopy with a reduced or discontinued service modifier and the facility uses modifier 73 or 74 depending on whether anesthesia had started. If the scope did not pass the splenic flexure, the procedure is coded as a sigmoidoscopy. The reason must be documented.

Anesthesia is billed on its own claim with the anesthesia code for lower GI endoscopy, and the claim must show whether the procedure was a screening or diagnostic service, using the modifier the payer requires. Some payers also have medical-necessity rules for anesthesia during routine screening, so their policy is checked in advance.

Psychotherapy codes are chosen by face-to-face time with the patient: 16–37 minutes for 90832, 38–52 for 90834 and 53 or more for 90837. The note should record the actual time, ideally with start and stop times. When billed with an E/M service, psychotherapy time cannot include time spent on the E/M.

The claim uses the place of service the payer requires — usually 02 or 10 depending on where the patient is — and a modifier showing the type of service, such as 95 for video, or FQ or 93 where audio-only care is allowed. Rules vary between Medicare, Medicaid and commercial plans and change often, so they are checked by payer.

Some health plans contract with a separate company to manage mental health and substance use benefits. Claims and authorizations for those services go to that company, often with its own payer ID and rules, rather than to the medical plan shown on the card. Sending a claim to the medical plan in that case leads to a denial.

Medicare ASCs bill their Medicare Administrative Contractor on the professional format — the 837P electronic claim or paper CMS-1500 — not the institutional format. Some Medicaid programs and commercial payers require the institutional format (837I or UB-04) with revenue codes instead, so the format is set for each payer.

It is Medicare’s list of surgical procedures it will pay an ambulatory surgery center to perform. It is updated each year in the hospital outpatient and ASC payment rule. If a procedure is not on the list, Medicare will not pay the ASC facility fee, so cases should be checked before they are scheduled.

For Medicare, most implants are packaged into the facility payment, while certain devices with separate pass-through status are reported and paid separately. Commercial contracts often carve implants out for separate payment, sometimes at invoice cost plus a percentage, and require the invoice. The claim must report them exactly as the contract specifies.

When an ASC performs more than one procedure subject to discounting in the same session, Medicare pays the highest-paying procedure in full and the others at a reduced rate. Procedures exempt from discounting are paid in full. Commercial contracts set their own rules, so remittances are checked against each contract.

Check whether the claim was actually filed on time. A clearinghouse acceptance report, payer acknowledgment or earlier remittance showing timely submission can support a reconsideration or appeal. Without proof, the amount is usually written off and cannot be billed to the patient. Working rejections daily prevents most of these denials.

Find the payer’s coverage policy for the service, compare it with the documentation and, if the criteria were met, appeal with the records that show it, quoting the policy’s own language. If the documentation is incomplete, the provider may be able to add a properly dated addendum. A letter from the treating provider explaining the clinical reasoning often helps.

Because the cause has not been fixed upstream. Correcting each claim recovers the money but leaves the process that created the error in place. Group denials by reason and payer, trace each group to the step where it starts — registration, authorization, coding or submission — and change that step.

CO (contractual obligation) means the provider is responsible for the adjusted amount under its contract or payer rules, and it cannot be billed to the patient. PR (patient responsibility) means the amount — such as a deductible, coinsurance or copay — is owed by the patient and can be billed to them or to a secondary plan.

Usually not. CO 45 means the charge exceeded the fee schedule or contracted amount, and the difference is a normal contractual adjustment. It should still be checked: if the allowed amount is lower than your contract says, that is an underpayment worth pursuing.

A claim adjustment reason code (CARC) gives the main reason a claim or line was paid differently from how it was billed. A remittance advice remark code (RARC) adds detail, such as which piece of information was missing. Reading both together usually tells you exactly what to fix.

Often, yes — if they are still within the payer’s filing or appeal limits, or if you have proof they were filed on time. Old claims are sorted by deadline, then by reason and value, and worked in that order. Claims past every deadline without proof of timely filing usually cannot be recovered.

Payers generally accept a clearinghouse acceptance report or payer acknowledgment showing the claim was accepted before the deadline, or an earlier remittance on the same claim. A report showing only that the claim was sent, or that it was rejected, is usually not enough.

Only after every recovery option has been checked — correction, reprocessing, appeal, billing a secondary plan or, where allowed, the patient — and when the balance cannot be collected. Each write-off should be approved under a written policy with a recorded reason, so patterns can be reviewed and fixed.

Yes. Old A/R can be handled as a separate project: we review the aging report, sort claims by deadline and recoverability, and work them while your team keeps handling new claims. The scope, timeline and pricing are agreed in writing first.

It depends on specialty, payer mix and how the figure is calculated, so a single target can mislead. The most reliable test is your own trend using the same calculation each month, together with the share of A/R over 90 days. A rising share of old balances is a warning sign whatever the overall figure.

With high-deductible plans, patients owe a larger share of many bills. If statements go out late or are hard to understand, those balances age and raise days in A/R. Estimating patient responsibility up front, collecting copays at the visit and sending clear, prompt statements keeps them moving.

Requirements vary by plan, but commercial and Medicare Advantage plans commonly require authorization for advanced cardiac imaging such as nuclear stress tests, cardiac CT and MRI, and PET, and sometimes for echocardiography and elective procedures. Many plans route imaging requests to a separate benefit manager, so check each plan’s current list.

It depends on the payer and the state. Psychiatrists, psychiatric nurse practitioners, psychologists and licensed clinical social workers are widely covered; licensed professional counselors and marriage and family therapists are covered by many plans and, since 2024, by Medicare. Each clinician must be credentialed with each payer.

It varies by payer and by how complete the application is. Medicare enrollment and many commercial credentialing processes commonly take from several weeks to several months. Starting as soon as a new provider signs, with a complete CAQH profile and all documents ready, is the best way to avoid gaps.

For Medicare, a provider can often bill for services up to 30 days before the effective date of enrollment, once enrollment is approved. Most commercial plans do not pay for services before the provider’s effective date. Holding claims until enrollment is approved, rather than billing under another provider, is the compliant approach.

CAQH ProView is an online profile where providers store credentialing information — licenses, education, malpractice coverage, work history — that many health plans use instead of their own application forms. Providers must re-attest that the profile is accurate every 120 days, or plans may pause credentialing.

Medicare requires most providers to revalidate their enrollment every five years, and DMEPOS suppliers every three. Commercial plans typically recredential providers every three years. Missing a revalidation can lead to deactivation and unpaid claims, so due dates are tracked for every provider.

A reassignment allows a group to bill Medicare and receive payment for services a provider performs. Each rendering provider in a group must have their benefits reassigned to the group through Medicare enrollment, and commercial plans have similar linking requirements. Without it, claims under the group are denied.

Each payer must be told about the new location — and, for Medicare, the enrollment record updated — before claims are billed from it. Providers working there may also need to be linked to it. Starting these updates before the location opens avoids denials for an unrecognized service address.

Some payers allow retroactive authorization, usually for emergencies or urgent care and within a short window; many do not for scheduled services. If a service was performed without required authorization, contact the payer promptly, request a retroactive review if available and, if the claim is denied, appeal with the clinical reason.

Contact the payer to update the authorization as soon as possible — many allow changes within a short time after the service. Approvals usually cover specific codes, units, a site and a date range, so any difference can lead to a denial even though an authorization exists.

A peer-to-peer review is a conversation between the treating provider and the payer’s physician reviewer about a pending or denied authorization. It gives the provider a chance to explain the clinical reasons for the service. Requesting it quickly, with the relevant records at hand, gives the best chance of a reversal.

Gold carding exempts providers with a strong history of approved requests from prior authorization for certain services. Some states, such as Texas, require it of state-regulated plans, and some payers offer voluntary programs. Eligibility and covered services vary, so check each state law and payer program.

A billing company that handles patient information is a business associate under HIPAA. It must sign a Business Associate Agreement before receiving any data and follow the HIPAA Security Rule, including access controls, individual logins, encryption, training and regular risk analysis. Ask how access is granted and removed, and where work is performed.

Yes. Ask where staff who access patient data are located. Offshore work is not prohibited by HIPAA, but some payer contracts and state Medicaid programs restrict offshore access to patient information, and you remain responsible for your business associates’ safeguards. The answer should be in writing.

No. Please send only practice and contact details. We do not collect patient information through website forms. When claim data is needed, it is exchanged securely after a Business Associate Agreement is signed.

A Business Associate Agreement is signed before any claim data is shared. Files are exchanged through a secure, encrypted method — never ordinary email — and only the data needed for the review is requested. Remittance and aging reports are usually enough.

No. The assessment uses reports your system already produces — such as aging reports and remittances — or read-only access you choose to grant. Nothing is installed in your systems.