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Medical Claims and Coding Analyst



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What physician wants to give any money back to an insurance carrier?  Few consumers realize that unlike other business owners, physicians don’t get to set their own prices for services rendered.  Rather, they are on a “take it or leave it” reimbursement system.  So, frustration runs high when a provider is informed that there has been an overpayment on an already heavily discounted service.  These overpayments, result in credit balances.

There seems to be an uptick in the number of practices that are contacted by the State Department of Revenue and told that they are the target of a credit balance audit.  This article, Juggling the Credit Balance Dilemma, is a good overview of why this is happening and the penalties you face if you don’t resolve credit balances.  We hope you take a minute to read the article and then make sure your practice is in compliance.

5 Common Reasons Your Claims are Bouncing Back

Billing is a complex and often tedious procedure, especially with ICD-10 codes. However, the reasons for returned and delayed claims often boil down to a few basics. Here are some of the most common billing mistakes practices make, and how to make sure your practice avoids them.

  1. Little Typos, Big Headaches

    Often reimbursements are delayed or denied because of very small, easy-to-make mistakes. “When I was assistant director of billing for a large multi-specialty practice,” says Brennan Cantrell, “the front office would often transpose the numbers or letters in policy number or omit a group number or plan ID. The front desk is extremely busy, and these are easy mistakes to make.” Cantrell, who is now commercial health insurance strategist for the American Academy of Family Physicians, says that the ideal solution is having an employee dedicated to watching for and correcting these errors. For small practices, this may not be a full-time employee, and the time saved by not having to resubmit claims might offset the time spent rooting out mistakes.

  2. Something’s Missing Here

    Sometimes payers delay payment because you didn’t send enough information. Often you can see this coming. “For example, when you file workers’ compensation claims, you will always need to submit documentation with the claim,” says Tammie Olson of Management Resource Group, an Ocean Springs, Miss., a firm offering financial management and support services for the healthcare community. “If you know you need to send the documentation to get a claim paid, do so when you file.”

  3. Please Ask First

    Another incredibly easy—but costly—mistake is not getting prior authorization. “Before you perform procedures, make sure you verify whether or not a prior authorization is required,” says Olson. “If it is, send in the request before scheduling the procedure.” And when you get ready to bill the procedure, “make sure the authorization number is on the claim,” she adds. Prior authorizations can be a pain, but having a routine for them when they are necessary can save time and prevent payment delays.

  4. Let Me See that One More Time

    Claims are increasingly denied because the patient’s coverage has been terminated or the plan or payer has changed.  Most of the time everything is just as it was the last time the patient came in but you should still ask to see the patient’s insurance card at every encounter. “People change insurance plans more often than they used to,” says Cantrell. “It’s a simple thing, but important.” Olson agrees, and adds, “If you do this, you should never have a claim denied for “policy terminated.”

  5. Keep up with the Changes

    Even when policies haven’t changed, what is and is not covered on a given plan sometimes does. You can be left holding the bag if a payer changes its policies about what procedures they cover or what labs they use, and you don’t hear about it. “Most payers send out a policy bulletin announcing these changes,” says Cantrell, “but it’s difficult to find time to keep up with this.” Large practices often have administrators who watch for these changes and pass the word on to each billing office. However, in smaller practices that job may fall to the front desk or billing staff. Make sure whoever does this understands the importance of carefully reviewing these bulletins when they are issued.


By: Avery Hurt

Ms. Hurt is a freelance writer based in Birmingham, Ala. Her work has appeared in publications including Newsweek, The New Physician, Muse, Parents, USA Today, and the Washington Post

A New Medicare Number For Your Patients

Medicare number

Medicare is going to be mailing all Medicare patients a new Medicare number and your practice needs to update their records.

In June, we posted an article about Medicare’s decision to stop using Social Security numbers.  Your patients likely call this their Medicare number. Since the transition date is looming ahead we thought an overview might be helpful.


  1. The effective date is April 2018.
  2. The new Medicare number will be called the Medicare Beneficiary Identifier (MBI).
  3. Your patients will get new cards with the MBI on the card.
  4. You will no longer be able to identify Railroad Retirement Board (RRB) members by their Medicare numbers.  You will be able to identify them by the RRB logo on their card.
  5. The MBI will have 11 characters.  It is unique to each person and will be clearly different from the HICN.
  6. The MBI is randomly generated so there is no link or hidden information related to the patient.
  7. MBIs will fit on forms the same way HICNs do.  You don’t need spaces for dashes.
  8. Here is an example of the way the MBI will look: 1EG4-TE5-MK73.


  1. Your office must be ready to accept the MBI by April 2018 for transactions such as billing, claim status, eligibility status and interactions with MAC.
  2. There will be a transition period when you can use either the HICN or the MBI to exchange data and information with Medicare.  The transition period will start April 1, 208 and run through December 31, 2019.  However, your systems must be ready to accept the new MBI by April 1, 2018.
  3. It is especially important that you are ready for people who are new to Medicare because they will only have the new MBI.
  4. Verify your Medicare patients’ addresses because they won’t get a new card if their address isn’t correct.
  5. Starting in June 2018, you can look up your patients’ MBI through your Medicare Administrative Contractor’s (MAC) portal when the patients can’t or doesn’t give them to you.
  6. You can get more information by visiting Medicare’s Card Home and Provider webpages at

Medicare has stated that they will “work closely with other payers, State Medicaid Agencies, and supplemental insurers to make sure the crossover claims process will still work”.  Please note that they are not guaranteeing it will work.

As with all things related to payers, Ben Franklin had the right saying, “Distrust and caution are the parents of security”.


Is Mod 59 a Magic Bullet?


Mod 59 codingWe’ve noticed an increase in the usage of modifier 59 (mod 59).  Oh we all want a magic bullet.  The code that will get every charge reimbursed the first time.   Although modifier 59 may get the claims paid it might not be the correct usage of the code.  After all there are no magic bullets.

Mod 59 does have a purpose. We asked a certified professional coder to explain when it should and shouldn’t be used.  Here is an explanation that you may find helpful.

Mod 59 is used on services that are commonly bundled and/or are not normally reported together. However, there are certain circumstances can be reported and paid separately.


Adding mod 59 indicates that a procedure or service is distinct or independent from other non-E/M services performed on the same day.  You can use modifier 59 when

  1. the procedure is performed in a different session or patient encounter;
  2. there is a different procedure or surgery;
  3. there is a different site or organ system; or
  4. a separate incision/excision and separate lesions or separate injuries not ordinarily encountered or performed on the same day by the same individual.

For billing, bill all services performed in one day on the same claim.  Add mod 59 to the subsequent procedure if the other procedures are not normally reported together and is appropriate for the clinical circumstances.


If a service is typically included in the performance of the primary procedure then the procedure is bundled and should not be reported with mod 59.  Modifier 59 should never be used when another more appropriate modifier exists to clarify the services performed and when the documentation does not support the separate and distinct status.

The Medicare National Correct Coding Initiative (NCCI) has also addressed the use of mod 59.  One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.  For more detailed information, click here for a copy of the related mod 59 article from the NCCI.

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