Woman answering the phone wearing scrubs

  1. Does the documentation justify the CPT and ICD10 billed? – Double check notes on visit to make sure there was enough documentation provided to use the provided CPT and diagnosis codes.  
  2. Were the modifiers appropriate or missing- denials can be an easy fix if an incorrect modifier was used or was missing.  Make sure correct modifiers are used for certain insurance plans!
  3. Are the TOS (type of service) and POS (place of service) codes correct? – super easy fix!
  4. Was the procedure bundled with another procedure?
  5. Were coverage guidelines followed? Check LCD and NCD.
  6. If denial doesn’t make sense CALL!


**Truly understanding your denial sets the tone for the next step**

Send corrected claim if….

  1. All items on claim are correct, this is payable!  SEND APPEAL!


1. Insurance verification- Most PM Software can double check insurance information right from the patient demographic page, or you can look it up either online or by calling. 


2. Referrals and pre-authorization- It is critical to know what insurance plans and what tests/procedures require pre-authorizations and referrals.  Most Tricare, Medicaid plans, and even some BC plans require this even on the first visit.  Best practice is to inquire on this for every patient, every time prior to visit. 


3. Demographic information- Patient demographics is one of the biggest help or hinderance in getting paid.  To avoid demographic problems, verify demographics at EACH visit and get Social Security Numbers whenever possible.  Checking demographics at each visit will ensure that the correct address, phone number and insurance is always on file.  

4. Collection of patient responsibility- Make sure staff is trained to collect co-pays, co-insurance amounts, deductibles and past due balances at every visit.  Collecting these amounts on the date of service will allow the billing process to run smoothly, lower AR, and hold the patient accountable for amounts due.  It is always easier to collect in person!


5. Documentation of visit- Are you documenting all you did?  Don’t leave any money on the table by missing billing for preventative care or counseling (Ex: smoking cessation)


6. Coding- Verify diagnosis and CPT coding is correct.  Diagnosis pointers on claims appropriately identify which CPT codes are tied to diagnosis codes!  


7. Claim submission: Do it right the FIRST time.  Are you set up to submit claims electronically?  Send as many claims as possible electronically!  Send appropriate documentation with workman’s compensation and auto carrier claims!

8. Identify Denial Trends quickly- Have an open and close relationship with our billers.  It is recommended to have monthly meetings to review denials and claim issues.


9. Do regular EOB (explanation of benefit) audits- Be sure you are being paid according to your contract.  It is recommended to have a fee schedule sheet compiled with your fees.  Medicare and Medicaid rates and commercial rates for easy quick verification.  


10. Collections of past due patient money- Be consistent and effective and have a solid collection plan in place.  Focus on the most delinquent accounts first!  Timely collection is key! 

Pre Authorizations don’t have to be such a headache!

Elite Coding and Billing offers pre-authorization services to suit your practices needs.

Reach out today for more info

How to protect your claims from pesky timely filing denials

Timely filing is when you file your claim initially to your primary, secondary or tertiary payer for the first time. The tricky part is all that goes into this process. While you and the staff are treating patients, closing notes, handling scheduling and referrals, pre-authorizations, amongst 1000 other tasks you are also responsible to be extremely well versed in the payer requirements of their “timely filing” rules.

Below we have given a few tips to assist you in preventing these potential denials

  1. Be sure Providers are aware of these payer rules. Pull reports of unsigned charts weekly to assure that charts are being signed and charges are going out far before your deadline.
  2. Have standards in place for payers with short timely periods (60, 90, 180). Check this A/R early and often. Watch for front end edits and denials and be sure they are worked immediately. You may need to submit a specific form or provide proof with your appeal. Check payer requirements.
  3. DON’T forget your secondary and tertiary claims. These may have their own set of rules based on that payer. Don’t let this revenue slip out of your hands.
  4. If a claim gets denied for timely filing review all steps of the billing cycle to be sure the denial was not a mistake. Payers love to deny for this reason praying we, as billers, wont catch it!

What happens if we make a mere mistake? No one is perfect!!Photo of an Insurance Claim form

Unfortunately, you will almost certainly see a denial. I do recommend to file the claim to show that the patient was seen and you have the record in your system. According to most contracts between providers and payers you will see a clause that the payer isn’t responsible for this claim and that you may not bill your patient. Of course, I would recommend you review your contract to be sure.

Review this denial with all the key players of your care team (providers, front desk, referral department, billing team, A/R team, IT/EHR specialist etc), find where the breakdown occurred. Use this example as a teaching tool to avoid future denials.

“If you’re early, you’re on time. If you’re on time, you’re late.”

Stay safe,



Are you unsure your billing practices are 100% accurate and you are getting paid for every claim? We offer FREE mini billing audits. Reach out today contactus@elitecodingandbilling.com

What is modifier 25?

Modifier 25 Description

 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

This is among the most common coding mistakes, costing medical practices millions each year in missed reimbursement opportunities and costing insurers millions each year in improper payments. This modifier, if inappropriately or overly utilized, leaves your practice open to audit risk.

How can we be sure we are staying compliant?

  1. Modifier 25 should always be attached to the E/M code. If provided with a preventive medicine visit, it should be attached to the established office E/M code (99211–99215).
  2. The separately billed E/M service must meet documentation requirements for the code level selected and must be identifiable in record. It will sometimes be based on time spent counseling and coordinating care for chronic problems.
  3. Be sure the same day procedure does not have a 90-day global period. If so, it would be more appropriate to report modifier 57 to the E/M.

Are you unsure your billing practices are 100% accurate and you are getting paid for every claim? We offer FREE mini billing audits. Reach out today at contactus@elitecodingandbilling.com