BC ADVANTAGE - January/February 2026

PROVIDING RESOURCES FOR MEDICAL PRACTICES AND THE PEOPLE BEHIND THEM

JANUARY / FEBRUARY 2026

MEDICAL CODING FOR LESIONS: GUIDELINES & TIPS WHY IS MEDICAL BILLING FOR LABS COMPLEX? DIAGNOSING DANGER: AI-GENERATED DIAGNOSIS IN MEDICARE ADVANTAGE CODING MEDICARE UPDATES: 2026 FEE SCHEDULE & IMPACT ON RADIOLOGY

STARTING A

MEDICAL BILLING BUSINESS

EDITOR’S NOTE Happy New Year! I hope everyone had a wonderful holiday season spent with your favorite people and your favorite things! After that peak excitement, when the holidays are behind us, some people experience the post-holiday slump, also known as the “New Year Blues.” One

editor Amber Joffrion, M.A. editorial@billing-coding.com

way to combat this is to make New Year’s resolutions. I have some that repeat from previous years, such as eating cleaner or spending less, and then there are always new ones, too. This year, my biggest goal is to start a new business. It is a writing endeavor, and I’m both nervous and excited about it. Change is often like that.

Similarly, our cover this issue, “Starting a Medical Billing Business: A Rewarding Venture for the Dedicated Entrepreneur,” written by Adam Phillips, CEO of American Business Systems,

ceo - publisher Storm Kulhan storm@billing-coding.com

emphasizes that with the new year, many people are “ready for a change.” Maybe you echo that sentiment, and you, too, have thought about starting a new business. In this article, Phillips details the essential steps to help you start a medical billing business, which is rewarding, both financially and personally—perhaps just the treatment needed for those “New Year Blues.” Yes, it will take determination and persistence, but doesn’t anything worth doing?

Our other articles attend coding lesions, billing for labs, AI-generated diagnoses, Medicare updates in 2026, cardiology billing, revenue boosts for ortho ASC, audit triggers, revenue

coo Nichole Anderson, CPC nichole@billing-coding.com

cycle optimization, front desk management, and time-based coding. There is truly something here for each and every one of our subscribers! Also, be sure to check out the reviews section for more helpful resources—and for something new! You asked, and we responded. We always appreciate your feedback—and your loyalty.

This issue marks 21 years of BC Advantage. Thank you to all of our loyal subscribers! When BC Advantage was launched, it was exciting to join this ever-changing and ever-growing—yet

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always stable—healthcare industry. Over two decades later, we are increasingly proud to be a part of it. To come alongside billers, coders, auditors, compliance officers, physician practice managers, and others in the medical practice, and provide resources to grow your knowledge,

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your career, and, ultimately, this industry.

In this new year, may you find ways to grow. To stretch yourself beyond your box or your comfort zone. When the day-to-day becomes mundane, may you seek ways to grow. A new year

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is the best time to make new commitments, whether it’s personal commitments to improve yourself, your finances, your relationships, or your character, or it’s career commitments, such as upskilling, networking, promoting, or finding that work-life balance. No matter what you decide to pursue this new year, be consistent. Challenge yourself to grow—and you will.

Change of address: Email subscriptions@billing-coding.com or call 864 228 7310

Editor Amber Joffrion, M.A.

BC Advantage is published bimonthly by Billing-Coding, Inc. P.O. Box 1388, Newland, NC 28657 BC Advantage Magazine www.billing-coding.com Phone: (864) 228 7310 Fax: (888) 573 7210 email: subscriptions@billing-coding.com / www.billing-coding.com

CONTENTS

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Starting a Medical Billing Business: A Rewarding Venture for the Dedicated Entrepreneur

Medical Coding for Lesions Guidelines & Tips

10

Boost for Ortho ASC

Why Is Medical Billing for Labs So Complex?

14

Diagnosing Danger: AI-Generated

Medicare Updates 2026: Fee Schedule & Impact on Radiology

for Diagnostic & Interventional Procedures

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and Evolving Coverage Policies

38 Revenue Cycle Optimization Through Coding Accuracy

42 Optimizing Front Desk Management

22 Cardiology Billing: Tackling Denials

4

34 Medicare Compliance: Avoiding Audit Triggers With Accurate Documentation

Diagnosis in Medicare Advantage Coding

18

26 How to Turn CMS Rule Into Real Revenue

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in Medical Practices

48 Time-Based Medical Coding

EXPERT CONTRIBUTORS THIS ISSUE Janine Mothershed is the founder and CEO of Coding Clarified, an innovative online medical coding school committed to transforming lives through flexible, highquality career training. https://codingclarified.com Kelsey Zaporowski writes for Collaborate MD. Collaborate MD’s technology solution optimizes clinical and financial workflows. They specialize In practice management systems and integrate with leading EHRs to provide the perfect combination of efficient frontoffice workflows and excellent back-office revenue cycle management. www.collaboratemd.com Dannilla Morgan, CPC, CBCS, is a seasoned medical coder specializing in risk adjustment and healthcare compliance with over 5.5 years of industry experience.

Sandy Coffta is VP of Client Services at Healthcare Administrative Partners. Ms. Coffta has over 17 years of experience in client relationship management, including reimbursement analysis, workflow optimization, and compliance education. www.hapusa.com Meghann Drella, CPC, is a Senior Solutions Manager at Managed Outsource Solutions (MOS), and is responsible for practice and revenue cycle management in the Healthcare Division. www. managedoutsource.com

Cosentus has established itself as one of the largest non-private, equity-backed RCM companies in the country, and has evolved into a 360-degree service solutions provider, transforming Revenue Cycle Management for healthcare practices and medical billing companies. https://cosentus.com/ Adam Phillips is CEO of American Business Systems, a 30+ year company devoted to helping individuals launch successful medical billing and revenue management businesses. www.absystems.com Loralee Kapp is a Solutions Manager at Managed Outsource Solutions, holding a degree in Health Information Management and Technologies. With over five years of experience in medical coding and health information management, she has been a valued member of the MOS team since 2021. www. managedoutsource.com Matt Kolinski, DO, is an Associate Management Consultant with DoctorsManagement. He has extensive experience spanning 20+ years as a practicing physician and entrepreneur. Dr. Matt has a passion for re-engineering the business of healthcare. With his hands-on experience in medicine, he combines his expertise and passion to perform practice assessments and feasibility studies and assist with practice startups. www.doctorsmanagement.com

Cosentus: With over 25 years of pioneering experience,

EXPERT CONTRIBUTORS THIS ISSUE

We are always interested in hearing from any industry experts who would like to get published in our national magazine.

Email us at editorial@billing-coding.com to request a copy of our editorial guidelines and benefits.

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5

MEDICAL CODING FOR LESIONS GUIDELINES & TIPS Lesions are abnormal changes in tissue that may appear on the skin, internal organs, or mucous membranes. They can be benign, premalignant, or malignant and are commonly treated in outpatient clinics, dermatology practices, and surgical settings. Accurate coding for lesion services is essential for proper reimbursement, compliance, and clean claims.

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How to Measure a Lesion for Coding Purposes Correct measurement is critical because CPT® codes for lesion excisions are based on size, not complexity.

Step-by-Step: Measuring a Lesion

1

Measure the lesion at its greatest diameter.

This is the widest part of the visible lesion.

2

Add both surgical margins.

The margins are the extra tissue the provider removes around the lesion to ensure complete removal.

Formula Lesion size + left margin + right margin = excised diameter

3

Use centimeters (cm).

CPT® codes require measurement in centimeters, not millimeters.

Medical coders may see documentation for several types of lesions, including: •

Benign skin lesions (e.g., skin tags, seborrheic keratoses)

•

Premalignant lesions (e.g., actinic keratosis)

•

Malignant lesions (e.g., basal cell carcinoma, squamous cell carcinoma)

Example •

Visible lesion: 1.0 cm

•

Left margin: 0.2 cm

•

Right margin: 0.2 cm

Total excised diameter = 1.4 cm

This final measurement (1.4 cm) determines the correct CPT® code.

What Not to Measure

•

Viral lesions (e.g., warts)

Coders should not use:

•

Suspicious or changing moles (nevi)

•

The length of the incision

•

The length of the sutured wound

•

The size of the final scar

Each lesion type directly impacts the diagnosis and procedure codes assigned.

Only the excised diameter is used for code selection.

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uncertain behavior)

Destruction vs. excision measurements: •

Excision procedures: Use the excised diameter (lesion + margins)

Key documentation elements needed for accurate ICD-10CM coding:

•

Destruction procedures (cryotherapy, laser, electrosurgery): Use the visible lesion size only, without adding margins

•

Type of lesion

•

Anatomic location

•

Laterality

•

Behavior (benign, in situ, malignant, uncertain)

Coding Tip: If margins are not documented, query the provider before assigning a code.

ICD-10-CM Coding for Lesions

CPT® Coding for Lesion Procedures

Diagnosis codes for lesions typically come from:

Destruction of lesions

•

L00–L99: Diseases of the skin and subcutaneous tissue

•

17000–17004: Actinic keratosis destruction

•

D00–D49: Neoplasms (benign, in situ, malignant, or

•

17110–17111: Destruction of benign lesions

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Code selection depends on:

Quick Reference: Lesion Measurement & Coding Tips

•

Number of lesions

•

Measure the lesion at its widest point.

•

Type of lesion

•

Add both margins for excisions.

•

Method of destruction

•

Do not measure the closure or scar.

•

Use centimeters.

Query the provider if the documentation is incomplete.

Excision of lesions •

11400–11446: Excision of benign lesions

•

•

11600–11646: Excision of malignant lesions

Best Practices for Lesion Coding

Codes are selected based on: •

Anatomical site

•

Excised diameter (lesion + margins)

Pathology and Laboratory Coding If specimens are sent for pathology: •

Use appropriate 88300–88399 CPT® codes.

•

Follow payor rules for bundling and global services.

•

Always wait for pathology when coding suspicious lesions.

•

Verify whether the procedure is bundled with other services.

•

Follow National Correct Coding Initiative (NCCI) edits.

•

Double-check payer policies for global surgical packages.

Quick Reference: Lesion Coding Tips •

Use 17000–17004 for actinic keratoses destruction.

•

Use 17110–17111 for the destruction of benign lesions.

Documentation Requirements for Accurate Coding

•

Use 11400–11446 for benign lesion excisions.

Look for:

•

Use 11600–11646 for malignant lesion excisions.

•

Code based on excised diameter, not closure size.

Medical Coding Path and Lab

•

Lesion size in centimeters

•

Margin sizes

•

Exact location and laterality

•

Number of lesions

•

Technique used

•

Pathology confirmation when applicable

Common coding mistakes to avoid: •

Using closure length instead of excised diameter

•

Coding excision when only destruction was performed

•

Assigning malignant codes without pathology confirmation

•

Not querying providers when margins are missing

Janine Mothershed is the founder and CEO of Coding Clarified, an innovative online medical coding school committed to transforming lives through flexible, high-quality career training. A Certified Professional Coder (CPC) and licensed AAPC instructor, Janine brings over a decade of experience in healthcare administration, medical coding, and workforce development. https://codingclarified.com

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Why Is Medical Billing for Labs So Complex?

Laboratory billing plays a crucial role in the healthcare revenue cycle, having a significant impact on a laboratory’s financial health and day-to-day operations. But too often, people see it as just another routine billing process, missing how important and complex it truly is.

Yes, it involves submitting claims to insurance companies and patients for lab tests performed.

However, lumping it in with general medical billing overlooks the unique challenges and intricacies that make it a specialized field.

The sheer volume of tests, diverse payor rules, and strict compliance standards create a level of laboratory billing complexity that demands specialized and advanced solutions.

And it is important to stress that this complexity isn’t just a sign of inefficiency within your lab; it’s a systemic issue.

From high test volumes to ever-changing regulations, the process is fraught with potential pitfalls that can impact your revenue and operational efficiency.

Understanding these nuances is the first step toward overcoming them.

This article addresses these challenges and more, helping you tackle complex billing issues and find solutions that meet your laboratory’s needs.

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This article will help you: •

Explore why laboratory billing is a complex and specialized process.

•

Understand common lab billing challenges and how they can significantly affect your revenue.

•

Discover the hidden costs of poor lab billing and the need for better processes.

•

Find out how implementing innovative laboratory billing software can help you navigate the complexities of billing and achieve sustainable financial health.

Understanding Laboratory Billing Basics At its core, laboratory billing is the process of creating and submitting claims for diagnostic services. When a lab processes a patient sample, it generates data that must be translated into specific codes, submitted to payors, and managed until payment is received. This entire workflow makes up the revenue cycle for labs.

Why Laboratory Billing Is So Complex Below, we take a deeper look into the factors that contribute to the intricacy of laboratory billing, making it a specialized area that requires an innovative approach.

Complexities include: •

One patient sample can result in multiple tests, which means one specimen can create several claims. This high volume increases the chance of mistakes and makes manual processing nearly impossible to scale effectively.

Key players in this process include: •

Patients: The individuals whose samples are being tested.

•

Physicians: The providers who order the tests.

•

Laboratories: The facilities that perform the tests.

•

Insurers: The public and private payors responsible for reimbursement.

•

While it shares participants with general medical billing, the similarities end there. The differences between medical billing versus laboratory billing are significant.

Unfortunately, these factors contribute to the common misconception that billing issues stem solely from staff inefficiency. In truth, the systemic nature of lab billing is inherently complex, which is the main reason behind some of your biggest concerns and challenges.

Frequent Coding and Payor Updates: The world of laboratory billing and coding is constantly changing.

This is due to payors frequently updating their coverage policies, reimbursement rates, and submission requirements; new CPT codes being introduced and old ones being modified; and molecular diagnostics becoming increasingly complex, with new technologies having a greater impact.

For instance, there is a lack of standardization across payors. Each of these (commercial insurance, Medicare, Medicaid) has different submission rules, prior authorization requirements, and reimbursement structures, making it hard to create a one-size-fits-all laboratory billing process.

For example, a single patient visit might generate one or two claims in a typical medical practice. In contrast, a single patient sample sent to a lab can result in multiple tests, each requiring its own claim line item, leading to a massive volume of claims that must be managed with accuracy.

This high volume, combined with other elements such as multiple payors, coding updates, compliance rules, complex testing, and denials, makes lab billing uniquely challenging.

These factors also make verification and claim processing more complicated.

Multiple Test Types and High Claim Volumes: Labs handle a multitude of tests, from simple blood work and basic metabolic panel to complex genetic sequencing.

Each test has a specific CPT code and reimbursement rate. For example, a basic metabolic panel (BMP) has its own code: 80048.

Keeping up with all these changes across dozens or even hundreds of payors is no small feat. If you don’t stay on top of it, you’re more likely to see a surge in claim denials.

•

Lab-Specific Compliance Requirements: Labs are also subject to stringent lab billing compliance regulations, such as the Clinical Laboratory Improvement Amendments or CLIA (which regulates clinical laboratories to ensure the quality of patient test results) and specific payor rules regarding medical necessity.

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For example, laboratories bear the responsibility of producing documentation, largely through Medicare audits, to show the medical necessity of the laboratory tests physicians order.

slowing down the entire billing cycle from the very beginning.

•

Dealing with all the documentation requests for basic lab tests can be a real administrative headache, and if you don’t handle them properly, claims get denied. It adds another layer of stress to your billing workflow.

Delays in Payments: The combined effect of these challenges is a significant delay in receiving payments.

Slow reimbursements disrupt cash flow, making it difficult to manage operational expenses and invest in growth.

Common Challenges Labs Face in Billing The Hidden Costs of Complex Billing The complex nature of lab billing comes with several ongoing operational hurdles that can affect your lab’s bottom line.

Inefficient billing processes do more than cause headaches; they create tangible financial and reputational costs.

Here are some of the key ones to watch out for:

These costs include:

•

Claim Denials and Resubmissions: Claim denials top the list as one of the most significant challenges in lab billing. They can occur for many reasons, including coding errors, missing information, or a lack of preauthorization. For example, payor-specific requirements for modifiers, such as QW for CLIA-waived tests, are often missed.

Reducing laboratory claim denials is a top priority, but the process of investigating, correcting, and resubmitting each denied claim consumes valuable time, money, and resources.

•

•

Manual Data Entry Errors: Despite technological innovations in Laboratory Information Systems (LIS) and billing platforms, many labs still rely on manual data entry or handwritten forms at some point in their workflow. This may seem like a minor issue, but it creates a significant ripple effect throughout your revenue cycle.

•

Lost Revenue: Every denied, delayed, or underpaid claim represents lost revenue. Over time, these small losses stack up, significantly impacting your lab’s bottom line.

For example, correcting a denied medical claim can cost a lab approximately $25 to over $100, according to The Medical Laboratory Observer. Some claims are never successfully resubmitted, turning into write-offs.

•

Higher Labor Costs: Managing a complex billing system manually requires a large administrative team. Hiring a lab billing specialist alone can cost, on average, $43,000 annually. Staff members also spend their days chasing down information, correcting errors, and appealing denials instead of focusing on higher-value activities.

•

Impact on Patient Satisfaction: Billing issues can create a poor patient experience. Unexpected bills or confusing statements can lead to frustration and damage the lab’s reputation with both patients and referring physicians.

Manual entry of order data adds more room for error, such as transposed numbers in a patient’s insurance ID or incorrect billing codes. These errors can lead to immediate claim rejections and payment delays.

The First Step Toward Simplifying Lab Billing

Time-Consuming Insurance Verification: Verifying a patient’s insurance eligibility and coverage for specific tests before processing a claim is crucial. However, this is often a manual and time-consuming process. Staff may need to call insurers or navigate complex online portals,

Confronting this complexity doesn’t have to be an uphill battle. The best way to smooth out your billing process is by using technology made just for labs. Modern lab billing software and automation tools can transform your revenue cycle.

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Positioning software as a solution is a natural response to the systemic challenges of lab billing. For instance, an automated system can instantly verify patient insurance eligibility, flag potential coding errors before a claim is submitted, and track claims in real-time. This proactive approach helps in improving laboratory billing accuracy from the start.

Pro-Tip Look for these features when adopting an advanced laboratory billing software solution: •

Easy Claim Control and Management: This automated feature easily sets tasks based on the line-item status of claims to prioritize your work and make sure you are quickly reimbursed for every dollar.

•

Automated Workflows: When selecting billing software, ensure it automates revenue cycle tasks such as insurance validation, claims review, corrections, denial management, and accounts receivable (A/R) management to save time and minimize errors. For example, when claim denial management is automated, labs can save money and time on denial re-work, followup, and administrative costs associated with claim denials.

•

•

Advanced KPI Reporting and Analytics: These are metrics that matter. This solution provides real-time insight into the financial performance and health of your account in an easy-to-understand visual format. Look for a system that allows you to build, run, and view multiple reports at one time, and easily share data with team members.

Easy EHR Integration and Implementation: When evaluating billing software, make sure it allows for seamless integration with your LIS and electronic health record (EHR). Also, ensure that the software is easy for staff to learn and offers a phased implementation approach with a dedicated enrollment specialist, ensuring you can switch software without missing payments.

The Path Forward: Enhanced Solutions Remember, laboratory billing is fundamentally different and more complicated than general medical billing due to its high claim volumes, intricate coding requirements, and strict compliance landscape.

This complexity is a systemic issue—not just a result of your staff’s inefficiency. And the fallout from these intricacies, such as manual work, claim denials, and payment delays, can really put a strain on your lab’s resources and hit your profits hard.

Embracing technology is the key to navigating this complexity. Laboratory billing solutions, like those offered

by CollaborateMD, including specialized software and automation tools, enable you to exert greater control over your revenue cycle. These tools can automate repetitive tasks, cut down on lab billing errors, and provide the insights needed for reducing laboratory claim denials.

By adopting more powerful, innovative solutions, you can streamline your operations, enhance cash flow, and focus on what you do best: delivering accurate and timely diagnostic services.

Kelsey Zaporowski writes for Collaborate MD. Collaborate MD’s technology solution optimizes clinical and financial workflows. They specialize In practice management systems and integrate with leading EHRs to provide the perfect combination of efficient frontoffice workflows and excellent backoffice revenue cycle management. www.collaboratemd.com

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Diagnosing Danger AI-Generated Diagnosis in Medicare Advantage Coding

The government is targeting companies and employees for adding diagnoses that allegedly fraudulently increase Medicare Advantage (MA) plan payments (“Medicare Advantage Provider Independent Health to Pay Up to $98 Million to Settle False Claims Act Suit,” 2024). This practice is happening more often due to AI programs that scan documentation and suggest diagnosis codes that might have been missed. The potential liability could be serious and widespread, especially if such conduct results in higher MA risk adjustment payments.

Corporate Responsibility and Oversight Organizations using AI must ensure that the output of AI generative tools is: 1) clinically valid, 2) auditable, and 3) compliant with Centers for Medicare and Medicaid Services (CMS) guidelines. Failing to properly govern AI tools may be considered negligence or willful ignorance (“Class-Action Suit Accuses Another Medicare Insurer of Using AI to Deny Care,” 2023).

False Claims Act Liability

Human Accountability

AI-assisted coding that leads to the submission of false or unsupported diagnoses violates the False Claims Act (FCA). Both organizations and individuals—including coders, auditors, and potentially AI vendors—can be held responsible under the FCA for submitting or causing the submission of false claims to the government for reimbursement.

Even with AI tools, human reviewers are responsible for final code selections. If staff members rely solely on AI’s recommendations as their only source of factual review and do not validate using MEAT (monitor, evaluate, assess, address, treat) indicators, they could be vulnerable to negligent or fraudulent coding. AI is helpful when used as a tool to assist (e.g., highlight potential diagnosis codes, identify missing MEAT elements), applied within a process involving human review, and trained with clinical context and current regulatory standards. However, the application of AI can worsen issues when it assigns codes automatically

For example, AI might suggest a diagnosis that lacks clear evidence in the clinical record and is submitted without human validation. This is a false claim.

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•

Policy: Establish internal policies for AI use in risk adjustment, including accountability, version control, and updates.

AI has the potential to either resolve or worsen coding issues, depending entirely on how it is implemented. The benefits of AI are realized when it is used ethically as a supportive tool rather than a decision maker. Coders are trained to verify codes assigned by AI using MEAT criteria.

Organizations allocate resources toward transparency, audit trails, and compliance reviews of AI outputs. It can also be used to identify missed or poorly documented diagnoses, enhancing coding completeness and accuracy without the risk of inappropriate adjustments.

without review, and organizations prioritize productivity over accuracy.

There is an overreliance on AI output, rather than clinician documentation (“AI in Healthcare: Opportunities, Enforcement Risks and False Claims, and the Need for AISpecific Compliance,” 2025).

Take proactive steps to compliance. Implement measures to ensure the ethical use of AI in coding.

For example: •

Human-in-the-loop validation: All code recommendations from the AI must be reviewed and validated by a certified coder.

•

Audits: Regular audits are conducted on AI-generated output to ensure compliance with CMS review standards.

•

Transparency in documentation: Ensure that decisions regarding coding (whether made by AI or a human) are supported by clearly documented clinical evidence.

For example, AI can identify missing documentation across multiple records that a human might have overlooked, helping capture clinically relevant data, prevent undercoding, and ensure reasonable reimbursement. AI becomes problematic when it is used to manipulate the system by maximizing risk codes regardless of medical necessity, there is no human oversight of the coding process, or when coders are instructed to accept AI suggestions without thorough review. Vendors and providers sometimes use AI to auto-code unsupported diagnoses to achieve higher payments (“Artificial Intelligence and False Claims Act Enforcement,” 2025). It is also employed in socalled “black box” coding, where coders need explanations for the diagnoses assigned, but the process’s auditability is questionable.

For example, AI could identify a chronic condition from a previous visit and use it for current-year coding without supporting documentation from the current visit, leading to unsupported Hierarchical Condition Category (HCC) coding.

The AI system might not distinguish between actively treated diseases and vaulted conditions unless specifically programmed to do so, which poses a significant issue for accurate coding.

Finally, coding practices can proactively promote the ethical use of AI by establishing governance frameworks that include compliance, transparency, and auditing, along with defining clear policies for AI use.

Define AI’s role strictly as assistive, not as an active coding tool. Ensure all AI-generated coding suggestions are reviewed and verified by humans.

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To do this: •

Prohibit automatic submission of coding work without the coder’s oversight. Require AI-specific compliance audits.

•

Regularly review coded charts for MEAT and clinical validity, and analyze for patterns of overcoding of findings or unsupported diagnosis coding.

•

Compare AI outputs with coder reviews to verify coding accuracy and identify biases. Be able to achieve transparency, auditability, and precise process rendering.

•

Use AI systems that offer explanations and traceability for their responses.

Require vendors to disclose the AI systems used, algorithmic change history, database references, training databases, and related details. Additionally, specify who reviewed and approved the coding documents to create an audit trail and ensure transparency. Invest in train-the-coder programs with ongoing oversight of coder compliance.

Train the institute on evaluating critical standards, assessing AI functional output, etc.

Expose and educate your coders about the pitfalls of unethical AI systems. Some issues will involve legal implications, as well as ethical concerns that must be communicated during train-the-coder sessions. Provide incentives for coders to report discrepancies or AI hallucinations. Consider compliance and other ethical issues when choosing vendors for AI or coding projects. Evaluate vendors based on their technology performance related to AI systems and on the legal aspects of the overall coding process. Require all vendors to prepare risk assessments, audit reports, and similar documentation for review.

Include AI compliance clauses in contracts to hold vendors accountable for errors or misuse of AI in coding. Foster a culture of ethical understanding.

The focus should be on coding accuracy, not profitability.

Encourage ethical practices identified by coders, such as unsupported AI suggestions. There isn’t enough coding education that specializes in integrating ethics into coding, with many saying it will be addressed later. This also involves legal considerations, including knowledge of and understanding the consequences of submitting invalid codes.

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Violations of the FCA, CMS sanctions, reputational harm, and other issues are just a few examples—risky business.

Without human oversight of AI systems and their recommendations that generate patient coding results, there is no transparency into AI analysis or real-time monitoring of the coding process (“Human Oversight in AI Medical Coding,” 2025). AI use becomes a clear liability for the organization. It’s important to understand that the risk isn’t eliminated by technology; it is actually worsened when ethical and governmental controls over its use are missing (“DevLicOps: A Framework for Mitigating Licensing Risks in AI-Generated Code,” 2025).

Dannilla Morgan, CPC, CBCS, is a seasoned medical coder specializing in risk adjustment and healthcare compliance, with over 5.5 years of industry experience. As a certified professional coder (CPC), she has a deep understanding of ICD10-CM guidelines, risk adjustment methodologies, and regulatory compliance. Her expertise spans multiple risk adjustment models, including CMS-HCC, HHS-HCC, and RxHCC, allowing her to interpret clinical documentation and ensure accurate code abstraction.

Beyond her professional expertise, she is a dedicated leader, serving as president of the AAPC Carmel, NY chapter and previously as member development officer. In these roles, she fosters professional growth, networking, and education within the medical coding community, and also manages a risk adjustment Facebook group, “The Risk Adjustment Coder’s Lounge,” of over 7,500 coding professionals.

Passionate about continuous learning, she is currently pursuing a BSc in Health Information Management to further expand her impact in the healthcare field. With her disciplined work ethic, a keen eye for detail, and a commitment to excellence, she continues to contribute to the integrity and accuracy of medical coding practices and advocate for medical coders.

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MEDICARE UPDATES 2026

FEE SCHEDULE & IMPACT ON RADIOLOGY The 2026 Physician Fee Schedule (PFS) Final Rule issued by the Centers for Medicare and Medicaid Services (CMS) contains very few changes from the Proposed Rule released in July. Although the Conversion Factors (CFs) are an increase over the current 2025 rate, they are slightly lower than in the Proposed Rule.

For the first time, there will be two different fee schedules in 2026 determined by a provider’s participation status in Alternative Payment Models (APMs). The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA 2015) contained a requirement that participants in APMs would receive an additional 0.75% annual update beginning in

2026, while non-APM participants would receive a 0.25% annual update. The CF for Qualified Professionals (QPs) will be $33.5675 rather than $33.5875 in the Proposed Rule; and for non-QPs, the CF will be $33.4009 rather than $33.4209 in the Proposed Rule.

Both CF calculations apply a positive 0.49% budget neutrality factor and a 2.50% increase that was contained in the July 2025 budget act (OBBBA), for a base CF increase of 3.0%. After the new APM participation updates, the final CF will be an increase of 3.77% for QPs and 3.26% for non-QPs. See Table 1.

Table 1 Conversion Factor for:

Qualified Professionals

Increase From 2025

Non-Qualified Professionals

Increase From 2025

2025 Actual

$32.3465

2026 Proposed

$33.5875

3.84%

$33.4209

3.32%

2026 Final

$33.5675

3.77%

$33.4009

3.26%

$32.3465

Many radiology practices are unable to participate in Alternative Payment Models as part of the Quality Payment Program (QPP). Therefore, it is likely that the majority of practices will receive reimbursement at the lower of the two rates for 2026.

The published CMS estimates of the rate of impact for radiology specialties are unchanged from the values in the Proposed Rule. These estimates are based on changes in RVU values, but they do not account for changes in the Conversion Factor. As we explain further below, the estimated impact will vary significantly depending on the site of service. See Table 2.

Table 2 Subspecialty

Imaging Center Global Fee

Hospital Professional Fee

Combined Impact

Interventional Radiology

7%

-7%

2%

Nuclear Medicine

1%

-3%

-1%

Radiology

1%

-3%

-2%

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Efficiency Adjustment The Final Rule confirms that the MPFS will include a -2.5% Efficiency Adjustment that would generally apply to all codes, except time-based codes, such as Evaluation and Management (E/M) services and services on the telehealth list. New procedure codes will also be exempted. These adjustments will take place every three years, using the Medicare Economic Index (MEI) productivity adjustment percentage with a lookback period of five years. According to analysis of the Proposed Rule by the American Medical Association (AMA), only 393 services will be exempt from the efficiency adjustment, and most specialties will see a payment reduction of 1%.

Site of Service Adjustment Beginning in 2026, the MPFS will begin to shift reimbursement away from services provided in a facility (hospital) setting and toward office-based services by reducing the portion of the facility Practice Expense (PE) RVUs allocated based on work RVUs to half the amount allocated to non-facility PE RVUs. However, the Final Rule

confirms our earlier reporting that this Site of Service Differential will not apply to services billed with Modifier -26. Thus, hospital-based radiologists will not be negatively impacted directly, but those who are employed by hospitals could feel future pressure as the institution’s technical component is reduced, affording them a smaller pot from which to pay the employed radiologists. Radiology practices billing globally for office-based services could benefit from the shift.

Geographic Practice Cost Indices (GPCIs) A Continuing Resolution (CR) passed by Congress in March 2025 extended the 1.0 work floor factor that is used to calculate the geographic adjustment of the Medicare fee schedule through September 30, 2025, and no action has been taken by Congress to extend it. As noted by CMS in the Final Rule, “The 1.0 work GPCI floor is established by statute and expired September 30, 2025. CMS does not have the authority to extend the 1.0 work floor.” The Geographic Adjustment Factor (GAF) tables contained in the Final Rule do not reflect the 1.0 work floor.

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Supervision Requirements

Other changes to the QPP rules include:

The MPFS Final Rule makes permanent the supervision flexibilities granted in 2020 during the COVID-19 pandemic.

Physician offices and IDTFs will have the ability to directly supervise certain diagnostic tests, such as Level 2 contrast administration, using real-time audio and visual interactive telecommunications technology. Note that both audio and video are required; audio-only connectivity is not sufficient.

•

Groups will have to attest to their specialty composition during the MVP registration process. CMS will no longer make this determination automatically.

•

Health Equity will be removed from the list of high priority Quality measures.

•

Achieving Health Equity will be removed from the list of Improvement Activities and replaced by a new Advancing Health and Wellness subcategory.

Quality Payment Program Similarly to the MPFS fee schedule changes, the 2026 rules that govern the Quality Payment Program (QPP) are not very different from what was in the Proposed Rule. The Final Rule confirmed that there will be six new MIPS Value Pathways (MVP) applicable to radiology, including pathways for both diagnostic and interventional radiology. There are six MIPS quality measures and three QCDR quality measures, 11 improvement activities, and one cost measure in the diagnostic radiology MVP. The interventional radiology MVP will have six MIPS quality measures and four QCDR quality measures, 19 improvement activities, and three cost measures.

Most of the other aspects of the MIPS rules remain unchanged for 2026, including the MIPS Performance Threshold, which will remain at 75 points through the performance year 2028. This is the level of points needed in 2026 to avoid a negative payment adjustment in 2028. The maximum negative adjustment will remain at -9%, with no provision in current law for future changes. The actual positive adjustment in 2028 available for QPP participation in 2026 cannot be determined until the reporting period is over.

The Final Rule affirms the Quality Category measure scoring policy established in 2025 that identifies certain measure sets affected by limited measure choice and adjusts the benchmarks of point-capped measures to allow for a maximum score of 10 points, extending the policy to MVPs.

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Participants in Advanced APMs are eligible for the enhanced fee schedule described above. Previously, the determination of Qualified Participant (QP) status was made at the group level, but beginning in 2026, such determination will be made at the individual level as well.

Conclusion The Final Rule mirrors the provisions laid out in the Proposed Rule with little change. The CF was modified slightly downward due to final calculations being applied.

The Efficiency Adjustment of -2.5% generated a lot of concern and advocacy activity among professional societies when it came out in the Proposed Rule, but they did not ultimately influence CMS’s final decision.

We will continue to analyze the impact of the MPFS Final Rule on radiology practices.

Sandy Coffta is VP of Client Services at Healthcare Administrative Partners.

Ms. Coffta has over 17 years of experience in client relationship management, including reimbursement analysis, workflow optimization, and compliance education. She specializes in business intelligence and reporting development, she is a subject matter expert in radiology practice billing, and she has deep expertise in resolving payor disputes and contract issues. www.hapusa.com

YOUR FULL SERVICE RADIOLOGY RCM PROVIDER www.hapusa.com info@hapusa.com

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| Issue 18.6

BC Advantage CEU/Webinar Library: The FAST, EASY, and AFFORDABLE way to earn your CEUs each year!

The IT Guy, if you have one, might be the person you direct questions to. But every user on a network must be aware of basic threats and know what to do when they see one. The “weakest link” concept applies and each user is a link.

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CARDIOLOGY BILLING

TACKLING DENIALS FOR DIAGNOSTIC & INTERVENTIONAL PROCEDURES Cardiology billing is one of the most intricate and high-stakes areas in healthcare revenue cycle management (RCM). With a wide range of diagnostic tests and interventional procedures, from stress tests and echocardiograms to catheterizations and stent placements, cardiology practices face significant billing challenges. It requires precise documentation, accurate coding, and strict compliance to meet complex and constantly changing payor rules.

Among the most pressing issues is the rising rate of claim denials. Both diagnostic and interventional cardiology services are governed by distinct billing rules, modifiers, and coverage policies. Diagnostic procedures, such as electrocardiograms and echocardiograms, require precise linkage between clinical documentation and ICD-10 codes 22

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to prove medical necessity. Interventional procedures, including angioplasty and cardiac catheterization, introduce additional challenges with global periods, bundled services, and detailed operative reporting. In such an environment, denials are not only frequent but also multifactorial.

Understanding the underlying causes of denials and implementing targeted preventive strategies is critical for cardiology practices and billing teams. This article explores the root causes of denials in cardiology billing and offers actionable strategies to prevent, manage, and recover from them. Whether you’re overseeing a high-volume diagnostic center or managing a multi-specialty cardiology group, these insights are designed to help you protect revenue, streamline workflows, and stay ahead of payor scrutiny.

Why Denials Are Common in Cardiology Billing Cardiology claims are more prone to denials than many other specialties because of the specialty’s technical depth, multiple procedural components, and payor-specific variations. While general healthcare billing typically sees claim acceptance rates between 85% and 90%, cardiology services often lag behind, averaging between 78% and 82%.

Common factors driving denials include: •

Coding Inconsistencies: A mismatch between CPT and ICD-10 codes, or between the physician’s operative report and coded services, is a major source of claim rejection.

•

Modifier Misuse: Cardiology billing frequently requires modifiers such as -26, -TC, -59, or -52 to clarify whether the claim covers the professional, technical, or distinct procedural component. A single incorrect modifier can invalidate the entire claim.

•

Incomplete Documentation: Missing procedure details, inadequate medical necessity notes, or lack of interpretation in diagnostic tests are frequent denial triggers.

•

Bundling Errors: Procedures that are incorrectly unbundled in violation of the National Correct Coding Initiative (NCCI) rules are routinely denied by payors.

•

Authorization Lapses: High-value diagnostic or interventional services, such as stress tests and cardiac catheterizations, often require prior authorization.

Skipping or mishandling this step leads to preventable denials.

Cardiology billing teams face additional difficulty due to differences in payor policies. What one insurer covers as a medically necessary diagnostic test might require additional documentation or prior approval under another.

This inconsistency makes a standardized billing process challenging, especially in multi-payor environments.

Beyond revenue loss, repeated denials also create workflow inefficiencies. Time spent reworking claims and pursuing appeals delays reimbursement and strains billing resources.

Recognizing these underlying patterns is the first step toward reducing denial frequency and building a more resilient revenue cycle.

Understanding and Preventing Denials in Diagnostic Cardiology Billing Diagnostic tests drive a large portion of cardiology volume and revenue, yet they also generate many preventable denials. Common diagnostic services include electrocardiograms, transthoracic, and transesophageal echocardiograms, stress testing, Holter monitoring, and nuclear imaging. Each requires clear clinical indication, accurate coding, and correct linkage to diagnostic documentation.

The common denial triggers for diagnostic cardiology are: •

Incomplete Clinical Evidence: Notes that do not explain symptom history, relevant exam findings, or diagnostic reasoning lead payors to question medical necessity.

•

Incorrect ICD-10 Linkage: A CPT code without an appropriate, specific ICD-10 code will often fail medical necessity edits.

•

Component Confusion: Many diagnostics have separate professional and technical components. Failure to bill 26 or TC when appropriate can cause denials or improper bundling.

•

Repeat Testing Without Rationale: Payors deny duplicate testing if there is no documented reason for repetition.

Modifier 91 must be supported by clinical context.

•

Authorization and Frequency Limits: Nuclear imaging and advanced modalities frequently require prior authorization or have payor-specific frequency rules.

Implementing these strategies can prevent denials: •

Link clinical indication to coding. Require a one-line clinical indication for every test. The indication must directly align with the ICD-10 code used for the claim.

•

Use structured documentation templates. Templates for test orders and reports should capture history, indication, relevant findings, and interpreted results to ensure compliance.

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•

Verify coverage and authorization early. During scheduling, confirm medical necessity rules, payor authorization requirements, and patient eligibility before testing.

•

Device and Supply Documentation: Payors require precise documentation of devices such as stents, balloons, or closure systems. Missing lot numbers or implant details can delay claim approval.

•

Apply component billing correctly. Train staff to distinguish professional interpretation from technical acquisition, using modifiers 26 and TC as required.

•

•

Document repeat testing rationale. When submitting repeat studies or using modifier 91, clearly explain the medical reason, time gap, and change in patient status.

Modifier Misuse: Modifiers like 59, XU, or 52 are frequently misapplied, causing either denials or payor audits. Each modifier must reflect the exact clinical scenario and follow NCCI edit rules.

•

Incomplete Procedural Notes: A brief or template note that omits fluoroscopy time, lesion location, or procedural intent fails to justify the billed service level.

•

Run targeted pre-claim audits. Use claim-scrubbing tools to flag mismatched ICD-10/CPT pairs, missing modifiers, and NCCI conflicts before submission.

•

Track and analyze denial trends. Review denials by payor and CPT to identify recurring errors, refine internal processes, and strengthen payor communication.

These steps reduce avoidable rework, shorten time to resolution, and strengthen any appeal when a denial does occur. Clear clinical linkage and front-end verification are the most effective defenses against diagnostic denials.

Coding and Compliance Pitfalls in Interventional Cardiology Interventional cardiology billing is among the most intricate areas of RCM. Procedures such as coronary angiography, stent placements, atherectomy, electrophysiology studies, and transcatheter valve interventions require granular coding that reflects anatomy, approach, and intent. Even minor gaps in documentation or code selection can lead to underpayment or outright denial.

Compliance essentials & best practices: •

Detailed Operative Reports: Each interventional note should specify the indication, vessels treated, method, devices used, complications, and final outcome. This ensures medical necessity and compliance with payor rules.

•

Accurate Use of CPT Add-On Codes: Interventions in multiple vessels require appropriate add-on codes. Coders must verify that documentation clearly supports each distinct intervention.

•

Preauthorization and Coverage Verification: Many high-cost procedures, including TAVR or EP ablation, demand prior authorization. Early verification prevents retroactive denials.

•

Regular Physician–Coder Collaboration: Coders and providers should review complex cases together to clarify documentation and validate coding accuracy before submission.

•

Internal Compliance Audits: Periodic reviews detect overcoding, undercoding, and documentation gaps. These audits help avoid payor scrutiny and reduce revenue leakage.

Key challenges unique to interventional cardiology: •

•

Complex Procedure Combinations: Multiple interventions are often performed during one session. Accurate reporting depends on identifying primary and secondary procedures, applying modifiers correctly, and avoiding code overlap.

Vessel and Site Specificity: Coding must capture which coronary arteries were treated, how they were accessed, and whether interventions were staged or repeated. Incomplete detail leads to bundling or loss of reimbursement.

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Addressing these details strengthens the defensibility of every claim. Precision in interventional cardiology billing is not only about reimbursement accuracy but also about maintaining compliance and transparency across every stage of care delivery.

Leverage technology for denial prevention.

Seven Strategies to Reduce and Appeal: Denials AI-driven claim scrubbing and rules-based engines can detect Preventing denials begins long before a claim is submitted.

Effective cardiology billing teams focus equally on front-end prevention and back-end resolution, using structured workflows, clinical alignment, and data intelligence to minimize lost revenue.

mismatched codes, missing documentation, or noncompliance with payor edits before submission. Automated alerts for authorization expirations and frequency limits reduce manual tracking errors and accelerate resolution.

Conduct multidisciplinary review.

To prevent and appeal denials:

Complex cardiology cases benefit from joint reviews involving coders, billing specialists, and clinicians. Reviewing documentation together ensures consistent interpretation of procedure intent,

Strengthen front-end processes.

especially in multi-stent or multi-vessel interventions.

Accurate data entry and pre-service checks remain the strongest

Effective denial management combines proactive controls with

defense against denials. Verify eligibility, confirm coverage limits, and ensure prior authorizations for high-value procedures like nuclear imaging or angioplasty. Use payor-specific checklists that include documentation and modifier requirements for both diagnostic and interventional services.

Invest in coder training and updates.

Cardiology coding changes frequently, especially for emerging interventions and revised CPT bundles. Continuous education on NCCI edits, payor-specific guidelines, and modifier application ensures claims are accurate the first time. Certified coders should review complex claims before submission to catch errors in vessel

rapid response mechanisms. When both are integrated into the billing cycle, denial volume drops, recovery rates improve, and the practice maintains a stable revenue flow even in high-complexity environments.

Strengthening Financial Outcomes Through Precision Billing: Cardiology billing requires balancing medical accuracy with financial detail. From routine tests to advanced interventions, success depends on clear documentation, accurate coding, and

coding, add-on codes, or medical necessity alignment.

payor-specific compliance. Denials aren’t just administrative errors;

Optimize documentation workflows.

Reducing denials in diagnostic and interventional cardiology

Encourage physicians to use structured templates that capture

requires close coordination between providers, coders, and billing

indication, procedure details, and device data. Real-time prompts

teams. When documentation is complete, coding is up to date,

within EHRs can remind providers to include critical elements such

and claims are validated with data-driven checks, reimbursement

as lesion sites, contrast volumes, and fluoroscopy time. The clearer

becomes smoother and more reliable.

the note, the stronger the justification during payor reviews.

The most successful practices treat billing as part of patient care—

Implement denial tracking and analytics.

they often reveal workflow or communication gaps.

prioritizing accuracy, accountability, and transparency. With strong processes, smart technology, and continuous training, cardiology

Every denial carries actionable insight. Tracking by CPT code,

teams can shift denial management from a reactive task to a

denial reason, and payor helps identify recurring issues such as

proactive financial strategy.

missing modifiers or outdated authorizations. Analytics tools can flag high-risk claims before submission and guide focused retraining or process changes.

Standardize the appeal process.

Meghann Drella, CPC, is a Senior Solutions Manager at Managed Outsource Solutions (MOS), and is responsible for practice and revenue cycle management in the Healthcare

A well-structured appeals workflow ensures denied claims don’t

Division. She has a formal education in medical coding and

linger. Assign responsibility for each appeal stage, set clear

billing and over 12 years of hands-on experience in the field.

timelines, and maintain standardized appeal letter templates

She holds a CPC certification with the American Academy of

referencing payor policy language and supporting documentation.

Professional Coders (AAPC).

For diagnostic tests, include clinical rationale and test results; for

www.managedoutsource.com

interventional procedures, attach operative notes and imaging evidence when permitted.

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How to Turn CMS Rule Into Real Revenue Boost for Ortho ASC The Centers for Medicare and Medicaid Services (CMS) has finalized its 2025 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) rule, which includes a big change for orthopedic practices with their own surgery centers. Starting in calendar year 2026, CMS is extending the policy that lets ASCs (Ambulatory Surgical Centers) receive the same annual payment update as HOPDs (Hospital Outpatient Departments).

For 2025, both ASCs and HOPDs will see about a 2.9% increase in their Medicare payment rates—as long as they meet quality reporting requirements.

How this change affects your revenue and earning potential:

This is important because at the same time, the Physician Fee Schedule (PFS)—which covers the professional fees you bill as doctors—is actually going down. CMS cut PFS rates by 2.9% for 2025.

Better Margins on Outpatient Cases

So while your professional fees are shrinking, your ASC facility payments are growing. For a small ortho group, this is a chance to keep margins healthy and protect earnings.

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If your ASC receives about $1M in total Medicare payments (allowable reimbursement) in a year, the 2.9% update would mean nearly $29,000 more in revenue—without changing your case volume. This provides more operational margin on high-volume procedures like TKAs, arthroscopies, and small joint surgeries.

Those extra earnings can be used to cover staffing, upgrade equipment, or just protect your bottom line as supply and labor costs keep rising.

A Leveler Against Hospitals Hospital-owned ASCs and HOPDs have historically enjoyed stronger updates than physician-owned centers. With CMS keeping the updates equal, you’re no longer stuck playing catch-up. It

improves. When margins are better, the risk of investing in new equipment or training goes down with the shorter break-even timelines.

makes your center more competitive and helps you retain referrals

Sheltering Revenue Against Professional Fee Cuts

that might otherwise shift toward hospital-owned facilities.

Professional fees under the PFS are dropping again in 2025, which hits many small groups hard. That means your professional fee

More Room to Add New CPT Codes With reimbursements nudging upward, the cost-benefit calculation for investing in new equipment or credentialing new procedures (e.g., outpatient spinal decompressions, robotic-assisted TKAs)

income is shrinking—but the ASC facility payment increase helps balance this out. That divergence can help buffer the financial impact of PFS cuts, especially for groups that bill both professional and facility fees.

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Strategies to make the most of this change: Ensure you meet quality reporting to capture the full increase. These payment updates only apply to ASCs that meet quality reporting requirements. If your ASC misses reporting deadlines, you don’t get the increase. Audit your current ASCQR (Ambulatory Surgical Center Quality Reporting) status now—ensure timely submission of all required data so you don’t leave money on the table.

Revisit your case mix. With improved reimbursement, lean into higher-margin cases, consider shifting more of your high-value cases to your ASC. For example, Medicare is steadily approving procedures like total knee replacement for the ASC setting. A higher payment update means those cases are more financially viable than ever.

Communicate with payors and referring physicians. Use this policy update to your advantage in payor negotiations—let referring physicians and commercial payors know you’re offering cost-effective, quality care with better facility rates aligned with Medicare trends. This helps you reinforce your value proposition versus HOPD options. Referring doctors may also be more likely to keep cases in your center if they know reimbursement is improving.

A Reimbursement Win You Can’t Overlook: CMS’s decision to extend equal updates to ASCs and HOPDs through 2026 is a real win for small orthopedic groups operating their own ASCs. While physician fee cuts are under pressure, this ASC facility payment lift delivers breathing room—soak it up where you can, reposition strategy, and lean in on your ASC’s long-term potential.

To translate that 2.9% bump into real impact, plan strategically: Stabilize margins, expand case mix, enable investment growth, negotiate smarter with payors, and make sure your quality reporting is airtight with good RCM support. You can convert this CMS rule into a bigger, brighter revenue forecast.

With our professional guidance, you can not only capture this increase but also find other areas to boost revenue, reduce denials, and keep your practice strong in a changing payment environment.

Bottom line: Don’t miss out on this opportunity. Turn CMS’s rule change into real dollars and long-term stability for your orthopedic group.

Model the financial forecast. Do a quick forecast. Run a quick margin simulation: Estimate revenue lift from the 2.9% bump across your case types, subtract any increased supply or staffing costs, and project net gain over the year. Even a small lift can add up to thousands of dollars, which could guide investment decisions (e.g., new instrumentation, capital improvements, staffing needs) and help offset inflation in supply costs.

Get expert revenue cycle support. The update is good news, but it also adds complexity—tracking quality data, staying compliant, optimizing coding, making sure denials don’t eat away at the extra margin—all these demand resources.

This is where a Revenue Cycle Management (RCM) partner can help.

A good RCM team will: •

Make sure your quality reporting is submitted correctly.

•

Help you code and bill procedures accurately so you capture every dollar.

•

Monitor payor denials and appeal aggressively.

•

Model how the CMS update affects your center’s long-term financial outlook.

That way, you can spend less time worrying about payment policies and more time focusing on your patients and growing your practice. Free your team to focus on care rather than reconciliation.

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Cosentus With over 25 years of pioneering experience, Cosentus has established itself as one of the largest non-private, equity-backed RCM companies in the country, and has evolved into a 360-degree service solutions provider, transforming Revenue Cycle Management for healthcare practices and medical billing companies.

Their services include Medical Billing & Coding, Complete Practice Management, and AI-Powered Software Solutions. They streamline operations and maximize revenue, allowing you to focus on patient care.

Cosentus utilizes advanced AI and Practice Management Software to boost reimbursements and minimize revenue leakage. Their expertise addresses low reimbursements, high deductibles, and operational costs. https://cosentus.com/

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STARTING A MEDICAL BILLING BUSINESS

A REWARDING VENTURE FOR THE DEDICATED ENTREPRENEUR As we head full speed into 2026, many physicians are ready for a change. At the beginning of each new year, after wearing many hats and dealing with ever-increasing administrative burdens, doctors are faced with some potentially life-changing decisions: Get some real help, or get out completely. Any medical billing company that positions itself as a strategic ally, and not just another vendor, is poised to take advantage of this “New Year Blues” phenomena.

As always, healthcare providers rely on accurate, efficient billing to keep their practices running smoothly, and demand for these services continues to grow. The issue is, most private practice staff members are overworked and/or underpaid and, in many cases, undertrained. They are often asked to manage the billing along with many other daily tasks. In a lot of cases, it makes more sense for the doctors to have the billing process done outside the office so they and the staff can focus on patient care.

This also addresses the current trend of “doctor burnout” (aka: isolation and loneliness) as a direct result of administrative/ paperwork burdens. Telling a doctor, “I got this,” so they no longer have to worry about billing issues is huge. Then make sure you have the skills and the technology to back it up.

Whether you are currently working as a biller or in a totally different industry, starting a medical billing business can be a rewarding opportunity—both financially and personally. With the right planning, training, and structure, you can build a business that not only supports your financial goals but also makes a meaningful impact in the healthcare community.

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Below are the essential steps to help you get started: Define your business goals.

The other neat thing about running a medical billing business is, you’ve got a lot of options when it comes to working full time, part time, doing the processing yourself, or hiring staff (you could even outsource your outsourcing).

Just looking for “side hustle” money, or do you want to take this to the moon? Setting clear goals will guide every decision you make, from how you market yourself to the technology you invest in. The good news is, you can play any role you want to. With medical billing, it’s up to you!

Research the industry and target market.

The U.S. medical billing industry is part of the multi-billion-dollar healthcare revenue cycle management market. According to recent studies (Precedence Research, “Medical Billing Outsourcing Market Size, Share and Trends 2025 to 2034”), the U.S. medical billing outsourcing market size was exhibited at USD 5.89 billion in 2024 and is projected to be worth around

USD 18.74 billion by 2034, growing at a CAGR of 12.27% from 2025 to 2034! Demand is being driven by two key trends: rising claim denial rates and physician burnout from administrative burdens. As mentioned previously, private practice doctors, in particular, often look for ways to outsource billing so they can focus on patient care.

Research your local market. Identify the specialties most common in your area—such as family medicine, pediatrics, or chiropractic—and consider how your services can meet their unique needs. National trends show that outsourcing is increasing across the board, but tailoring your approach to local practices will help you stand out. For those just

starting out in this industry, specialties such as behavioral health, social work, physical therapy, and chiropractic make excellent first clients. They are usually solo providers that you can meet at local networking events, and the billing work is relatively simple, allowing you to get your feet wet and then move on to bigger clients. American Business Systems can help people find their target markets.

And no, AI isn’t taking over completely. You need to learn how to use AI tools to be more efficient, but the nuances of billing/coding will always require a human to sign off.

Check out my previous BC Advantage article on this topic.

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Write a business plan: A business plan can be helpful, but I caution you not to get hung up on it. Some people are guilty of “analysis paralysis” and they either don’t launch at all, or take longer due to being afraid of stepping outside the boundaries of the “plan” (hint: it’s ok to break the rules.

A business plan should outline: •

•

•

•

Services you’ll offer: Insurance billing, patient billing, denial management, credentialing, etc. The more services and solutions you can offer, the more you are able to help doctors and stand out from people just offering billing services alone. If you don’t want to do the work yourself, you can partner with others who can, and mark up fees so that there is some profit for you as well.

Pricing structure: Percentage of collections vs. flat fee. You need to understand what the real picture is in the practice in terms of current denial percentages, outstanding A/R, etc. You don’t want to end up pricing yourself too low and spending more time on claims than it’s worth.

Technology requirements: Billing software, clearinghouse connections, HIPAA-compliant tools. A secure, cloudbased system is the only way to go. Choose a software company that is always taking care of backups and updates, etc. and is certified for any and all government payment models and initiatives. The best choice is a system with a built-in clearinghouse as well so you don’t have to worry about finding your own.

Marketing strategy: How you’ll reach doctors and decision-makers. You’ll want to utilize multiple proven techniques to cast the widest net.

Some additional costs you might incur include: •

Creation of Entity (LLC, etc.) - $100-$500

•

Basic Home Office (computer, printer, phone line) $500-$2,000

•

Insurance - $500-$1,000/year

•

Website Hosting/Email - $200-300/year

•

Trade Show Booth Rental - $500-$1000

•

Networking Group Fees (BNI, etc.) - $0-$1,500/year

•

Online Ads for Sales Reps - $75-$300

•

Mass Mailers - $500-$800

•

Printed Marketing Materials - $300-$800

Set up your business structure.

Decide how you want to legally structure your company: sole proprietorship, limited liability company (LLC), or corporation.

Many new owners choose an LLC for the balance of flexibility and liability protection. Check your state’s requirements and consult a professional if needed to ensure you’re setting things up correctly from the start. I’d recommend using a site like https://www. zenbusiness.com.

Choose and register your business name.

Your business name should communicate professionalism and trust. Once you’ve chosen a name, verify availability through your state’s Secretary of State office. Register your business and secure a domain name for your website to build credibility with potential clients. You also want to consider a name that is easy to understand and spell, and you want your website domain name to be easy to verbally communicate and be as short as possible.

A strong business plan not only clarifies your direction but also makes it easier to secure financing if needed.

You would almost always want a “.com” domain if you can get one. Consider leaving the word “billing” out of your name. Why? It’s limiting. For example, use terms like “revenue management” or

Secure financing.

“cash flow solutions” to broaden your reach.

Starting a medical billing business has relatively low overhead compared to other industries and franchises. Many entrepreneurs launch from a home office with just a computer, billing software, and training. Still, you’ll want to account for upfront costs such as certification courses, marketing, and technology subscriptions.

Financing options may include small business loans, personal savings, or even credit cards. You’ll need an excellent credit score to get approval with most banks.

Obtain necessary licenses and compliance certifications.

Medical billing is heavily tied to patient data, so HIPAA compliance is essential. Make sure your software applications are certified HIPAA compliant because your clients will expect you to have a Business Associate Agreement (BAA) that states your systems are certified. While you don’t need a special “billing license” in most states, you may need a general business license or permit. More importantly, you’ll want to demonstrate your expertise through

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certification or training programs that cover billing processes,

e-books as a lead magnet to attract customers. Pro Tip: Proper

software, and compliance standards. There are several widely

follow-up is vital. When you talk with a prospect, you want to

accepted certifications that you can get through organizations

stay in touch with them until they are ready. Automated emails

such as AAPC, AMBA, and HMBA. If you feel that you need help

and texts are by far the best way to do this. A “no” does not

with business development and marketing of the business, you

mean “never.”

want to check and see if any of these organizations provide anything like that. Most do not. Note that there isn’t one particular

•

you secure your first clients. Do a good job for one doctor, and

certification that you are expected to have. You also do not need

you can bet they will spread the word to other doctors. And in

to be certified in coding, unless you are focusing on that particular

this industry, you can have clients anywhere in the USA.

aspect as a service (hint: you can hire a coding partner to do this).

Build your office—physical or virtual.

Referrals from existing clients. This is extremely powerful once

•

Direct mail, trade shows, and sales reps. These are all “tried and true” methods” to market your business.

Most medical billing businesses operate remotely, which keeps

Remember: you’re not just offering billing services—you’re helping

overhead low. You’ll need a reliable computer, secure internet,

practices get paid faster, reduce administrative stress, and improve

billing software, and data backup systems (unless your software is

financial health.

cloud based and backups are taken care of for you). If you plan to scale your business, you may eventually add staff or rent an office,

Why Medical Billing Is Worth Considering

but many owners build successful companies entirely from home.

Market your business.

Healthcare is one of the most stable industries in the U.S., and outsourcing billing is no longer just for large hospitals. Small and

This is a big one. You need a very clear step-by-step, multi-pronged

mid-sized practices increasingly recognize the value of working

marketing approach that will generate interest from doctors

with billing professionals who can keep up with ever-changing

and office managers. Doctors and practice managers are busy

insurance rules. For motivated entrepreneurs, this means a steady

professionals, so your outreach needs to be clear and concise.

pipeline of potential clients.

With determination, training, and persistence, your medical billing

Strategies may include:

business can be more than just a source of income—it can become a sustainable, flexible career that grows with the healthcare

•

Networking with local practices and attending medical

industry itself.

associations. You also want to find and build relationships

•

•

with “power partners” through networking (BNI, Chamber of

Adam Phillips is CEO of American Business Systems, a 30+

Commerce, Meetups, etc.) that work with doctors in other

year company devoted to helping individuals launch successful

industries and can refer their contacts to you. Some great

medical billing and revenue management businesses. He

examples would be financial advisors, CPAs, attorneys, realtors,

has been able to help medical billing business owners stay

and IT companies.

profitable during several economic downturns and a worldwide

Online presence. This includes a professional website and

pandemic. Adam has helped hundreds of entrepreneurs achieve

LinkedIn/Alignable profile. Don’t worry much about SEO or

their dreams of owning a profitable business by leveraging

Google ads in the beginning. It’s not cost effective compared to

relationships with some of the largest health information

the networking mentioned above.

technology companies in the world.

Educational marketing. Consider webinars, articles, or case

He co-authored a book “9 Ways Doctors Let Money Slip Through

studies that showcase your knowledge. I recommend using

Their Fingers” to help doctors in private practice change habits

e-books as powerful lead magnets. You could even host a live

to build more wealth and collect more revenue.

“lunch and learn” and speak on an important industry topic (or hire someone else to speak).

•

www.absystems.com

CRM/Follow-up system. You’ll want to have a way to manage your leads, prospects, and current customers. You do this with a Customer Relationship Manager (CRM)—and there are many to choose from. At American Business Systems, we use Zoho CRM and have built an automated email campaign that offers BC Advantage Magazine

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MEDICARE COMPLIANCE

AVOIDING AUDIT TRIGGERS WITH ACCURATE DOCUMENTATION AND EVOLVING COVERAGE POLICIES Medicare coverage policies such as National and Local Coverage Determinations (NCDs and LCDs) are continually updated to reflect advances in medical technology and care delivery. Compliance depends on accurate, complete, and timely documentation that supports the medical necessity of every billed service.

Recent audits from the Office of Inspector General (OIG) and CMS highlight persistent compliance gaps. For example, a 2020 hospital audit found that nearly half of reviewed claims were noncompliant, while a home health audit uncovered $2 million in overpayments due to documentation errors.

The Centers for Medicare and Medicaid Services (CMS) uses audits and data analysis to detect billing errors, overpayments, and potential fraud. Noncompliance can lead to penalties, repayment demands, and reputational damage—making strong documentation practices essential for both financial and professional stability.

Understanding and knowing how to avoid Medicare audit triggers and maintain documentation requirements is essential for implementing compliance best practices.

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Common Audit Triggers in Medicare Claims and How to Avoid Them Triggers for Medicare audits typically include data-driven outliers, documentation errors, and noncompliance with coding or coverage rules. Understanding these risk areas helps providers stay compliant and protect revenue.

Common audit triggers include: Unusual Billing Patterns: Billing significantly higher or more frequently than peers in the same specialty can draw CMS attention. Consistently reporting high-level E/M codes (like 99215) for routine visits may signal overbilling.

For example, billing complex visit codes for stable diabetic patients seen for simple medication refills may not meet medical necessity criteria.

Avoid it by: Reserving high-level E/M codes for complex cases such as acute chest pain or respiratory distress that require detailed evaluation or urgent care.

Upcoding and Downcoding: Reporting a higher level of service than documented (upcoding) or repeatedly undercoding to avoid scrutiny both violate compliance standards and can prompt audits. Both practices distort the true level of care provided and invite compliance scrutiny.

Avoid it by: Ensuring documentation fully supports the level of service, medical decision-making, and time spent, and aligns with current CMS and payor guidelines.

Inconsistent or Insufficient Documentation: Common documentation issues that attract Medicare scrutiny include copy-paste or cloned notes in EHRs, missing medical necessity documentation, and mismatched visit notes and billed codes.

Avoid it by: Confirming that every note clearly supports the billed code, accurately reflects the patient’s condition, and includes justification for all ordered services.

High Volume of Claims or Rapid Reimbursement Growth: A sudden spike in billing or reimbursement without a valid explanation may suggest upcoding, unbundling, or billing errors, and raise red flags.

Avoid it by: Tracking billing patterns, documenting reasons for volume changes (e.g., new service lines), and conducting internal audits to verify accuracy.

Frequent Claim Denials or Resubmissions: Recurring denials often indicate underlying compliance or

documentation problems, triggering audits.

Medicare uses data analytics to identify unusual billing trends, high error rates, excessive appeals or resubmissions and denials involving high-cost or prior authorization services.

Avoid it by: Identifying root causes of denials, correcting coding/documentation gaps, and improving front-end verification and claim review processes.

Improper Use of Modifiers: Overuse or misuse of modifiers (e.g., -25, -59, -24) to bypass edits or justify multiple services can trigger audits. For example, appending modifier -25 to every office visit with a minor procedure—even when no separate E/M service was performed—indicates possible misuse.

Avoid it by: Staying current with CMS and payor-specific modifier guidelines, using modifiers only when criteria are met, ensuring documentation supports their use, and performing periodic modifier audits.

Noncompliance with Coverage or Coding Updates: Using outdated CPT or ICD-10-CM codes, or billing services no longer covered by Medicare, can automatically flag claims for review.

Avoid it by: Staying current with CMS transmittals, quarterly code updates, and NCD/LCD revisions. Conduct regular internal audits and provide ongoing coder education to ensure full compliance.

Regular internal reviews, strong documentation practices, and proactive monitoring of CMS updates are the most effective ways to prevent these Medicare audit triggers and maintain compliance.

Accurate Documentation: The Foundation of Audit Readiness Accurate documentation is the foundation of Medicare compliance. Every billed service must be medically necessary and fully supported by the patient’s record.

Clear, complete notes reduce audit risks and provide strong defense if a review occurs. Incomplete or illegible documentation can lead to payment denials—even for normally covered services.

Documentation should reflect the patient’s condition, care provided, and rationale for the selected codes. For example, Medicare Part B covers outpatient services such as office visits, diagnostic tests, and preventive care.

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Each entry should clearly show: •

The reason for the visit or service

•

Date of service

•

Relevant medical history

•

Test results and findings

•

Diagnosis or assessment

•

Treatment plan

Comprehensive documentation not only supports higher-level E/M coding compliance when justified but also strengthens claim validity and helps defend against denials.

Staying Current With Evolving CMS Regulations and Updates

Be sure to: •

Create a Medicare compliance checklist focused on high-risk areas (E/M coding, modifier use, and medical necessity).

•

Compare billing trends with CMS benchmarks to detect anomalies.

•

Conduct annual risk assessments and RADV reviews for accuracy and transparency.

2. Implement staff training on coverage and coding updates.

CMS frequently updates rules and coverage criteria.

Make sure you: •

Schedule quarterly education sessions for coders, billers, and clinicians.

•

CMS updates its Medicare coverage policies annually to align with new clinical evidence, technology, and healthcare delivery models.

Include real audit findings in training to reinforce accountability.

•

Emphasize how documentation supports medical necessity and coding accuracy.

Key updates for 2025 include:

3. Use AI-enabled tools and EHR

•

Medicare Physician Fee Schedule: Conversion factor decreased by approximately 2.83% (from $33.2875 to $32.3465).

•

Telehealth: Key flexibilities extended through September 30, 2025, with some behavioral health services made permanent.

•

NCCI Policy Manual: Revisions to code pair edits, modifier guidance, and bundling logic.

•

Part B Coverage: Updates to clarify coverage for certain outpatient drugs and services.

•

Cost-sharing adjustments: Revised deductible and coinsurance requirements for select services.

CMS’s 2026 updates include changes to premiums, prescription drug costs, and program policies. Staying informed and adapting to these changes is essential for correct billing and payment.

Three Strategies to Strengthen Medicare Compliance 1. Conduct regular internal audits and risk assessments Regular audits are the backbone of a solid compliance program. They help identify billing errors, improper codes, and documentation gaps before they lead to penalties.

Leverage technology to improve accuracy and reduce manual work.

Ways you can do this: •

Use AI-driven audit tools to detect documentation gaps and coding errors.

•

Apply NLP and predictive analytics to validate that notes meet CMS standards.

•

Automate internal audit triggers to maintain real-time compliance visibility.

Building a Culture of Compliance Staying Medicare-compliant is not a one-time effort; it is an ongoing process that protects both revenue and reputation. When documentation is accurate and policies are consistently updated, claims are paid faster, denials are reduced, and audit risks decline. A strong compliance culture helps providers deliver better patient care while maintaining the integrity of their reimbursement.

Loralee Kapp is a Solutions Manager at Managed Outsource Solutions, holding a degree in Health Information Management and Technologies. With over five years of experience in medical coding and health information management, she has been a valued member of the MOS team since 2021. www.managedoutsource.com

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REVENUE CYCLE OPTIMIZATION THROUGH CODING ACCURACY Revenue cycle management is the sequence of administrative and clinical functions that capture, process, and collect service reimbursements. In today’s healthcare environment, those payments flow through diverse models such as fee-forservice claims, value-based agreements, and bundled payments.

Coding sits at the center of that sequence because accurate codes translate services into billable claims across all of these cost structures. When codes are incorrect or incomplete, claims deny, appeals begin, and accounts receivable age.

However, coding precision is not a one-time technical task. It’s a continuous process that

The Role of Coding Accuracy in Revenue Cycle Optimization Every claim begins with documentation and ends with reimbursement. Every step, from patient registration and charge capture to claim submission and payment posting, forms the foundation of revenue cycle management. Code assignment acts as the bridge between these RCM stages, converting clinical narratives into standardized data that determines payment accuracy and speed. Even small errors can negatively impact the entire flow, leading to delayed reimbursements, increased denials, and compliance risks that strain both revenue and resources.

Here are the key ways code accuracy directly shapes revenue cycle performance: •

Claim Submission: Clean, accurately coded claims are processed faster and with fewer rejections since payor systems easily match the codes with covered services.

•

Denial Management: Correct codes minimize denials caused by mismatched or incomplete data, reducing administrative workload.

supports compliance, drives quality reporting, and improves operational performance.

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•

Compliance: Adherence to ICD-10, CPT, and HCPCS guidelines protects against penalties and audit risks.

•

Reimbursement Integrity: Proper documentation and coding ensures reimbursements reflect true service value, avoiding both underpayments and overpayments that can raise compliance flags.

•

Revenue Insights: Key RCM metrics remain reliable, as code accuracy affects days in accounts receivable, denial rates, and net collection ratios.

In short, the connection between medical codes and revenue outcomes is direct and measurable: •

Documentation quality determines how completely a coder can represent clinical care.

•

Data integrity determines how correctly the claim represents that documentation.

•

Claim performance determines how quickly payment is received and how much effort is spent on appeals.

•

Financial results then influence resource availability for training, technology, and process improvement, bringing the cycle full circle.

For any practice, recognizing this relationship is the first step that defines how efficiently the entire cycle functions.

•

Each of these errors multiplies the administrative workload.

Staff must spend a substantial amount of time correcting and resubmitting claims, performing secondary review, and appealing denials. Over time, this creates bottlenecks that increase operational costs and slow down cash flow, affecting financial stability of the practice.

How Accurate Coding Impacts Financial Performance Accurate data capture is one of the strongest drivers of financial performance in healthcare. It determines how efficiently claims move through the revenue cycle, how quickly reimbursements arrive, and how reliably practices maintain compliance. Compliant codes strengthen financial performance while improving transparency and integrity across administrative, clinical, and payor teams.

Accurate coding results in: •

The Cost of Inaccurate Coding

Some of the most common issues include: Incorrect Code Assignment: Misclassification of procedures or diagnoses can trigger denials or underpayments.

•

Incomplete Clinical Documentation: When physician notes lack specificity, coders cannot assign accurate codes, leading to claim denials or rejections.

•

Use of Outdated Codes: Neglecting annual code set changes and submitting claims with retired or obsolete ICD, CPT, or HCPCS codes can lead to claim rejections or compliance violations.

•

Inconsistent Coding Practices: Lack of standardized processes across teams results in coding discrepancies that lead to revenue leakage and lost reimbursement opportunities.

Stronger Claim Performance: When the codes precisely reflect the services delivered and diagnoses documented, payors are more likely to approve claims on first submission. This reduces denials and shortens days in account receivable.

Review frequent denial reasons to identify underlying patterns that cause recurring denials. Track first-pass acceptance rates and denial percentages by payor, specialty, or procedure types. Provide coders with timely feedback from payor audits to continuously improve accuracy.

Inaccuracies in code assignment can quietly erode operational efficiency, profitability, and patient satisfaction.

•

Improper Modifier Usage: While modifiers are essential to clarify procedures and ensure accurate billing, incorrect or missing modifiers may trigger payor scrutiny, leading to denials, fines, and reputational risk.

•

Improved Compliance: Accurate codes protect healthcare organizations from compliance violations and payor scrutiny. Documentation that supports each code forms the basis of audit defense.

Schedule internal coding audits at regular intervals to ensure ongoing accuracy and compliance. Identify highrisk procedure codes and complex diagnosis combinations for targeted review and expert validation. Keep training current with updates to ICD-10, CPT, and HCPCS guidelines.

•

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influences reimbursement. Each diagnosis contributes to a patient’s risk profile, which in turn affects payment rates. Incomplete or non-specific codes can understate patient complexity and result in lower revenue.

Capture chronic conditions and co-morbidities consistently in every reporting period. Align coders and clinicians on documentation standards required for risk adjustment. Use data analytics to uncover coding gaps within high-risk patient populations.

•

Greater Operational Efficiency: Precise codes streamline workflows across billing and collections teams. With fewer denials and resubmissions, staff can focus on revenue optimization rather than administrative corrections.

Automate basic edit checks to detect mismatched or missing codes before claims are submitted. Integrate advanced coding tools to balance coder speed with quality reviews and maintain accuracy standards.

Measure both turnaround time and coding precision using KPI metrics to improve overall throughput.

•

Coding errors don’t just slow down payments; they drain administrative resources, trigger denials, and invite regulatory scrutiny from payors and government bodies.

Addressing them requires more than one-off audits or irregular training. Practices should implement practical strategies that optimize the entire coding and billing process to not only improve accuracy but also detect errors early, support cleaner claims, and strengthen financial performance.

To improve coding accuracy: •

Invest in coder training and updates. While advanced tools can enhance speed and productivity, technology alone can’t prevent coding errors. Coders need up-todate knowledge and reliable resources to apply codes correctly. Continuous education ensures that staff stays current with ICD-10, CPT, and HCPCS updates, as well as evolving payor-specific rules. Structured training programs, access to coding references, and access to expert feedback help coders make informed decisions quickly. When teams are well-informed, errors are reduced, claims move faster, and the revenue cycle stabilizes.

•

Leverage automations and AI coding tools. Technology plays a critical role in improving coding accuracy and operational efficiency. Automation and AI-driven tools can analyze clinical documentation in real time, suggest suitable codes, and flag inconsistencies that might otherwise result in denials. These systems reduce manual effort and accelerate claim preparation but they’re not a substitute for human expertise.

Enhanced Patient Financial Experience: Errors in coding often translate into unclear bills that confuse patients, trigger complaints, and slow down collections. Accurate coding ensures that statements reflect true costs, preventing disputes and delays in patient payments.

Integrate coding checks into billing workflows to catch inconsistencies before statements reach patients. Present charge details clearly to build trust and minimize billingrelated complaints. Track patient feedback on billing accuracy as part of quality improvement.

•

Strategies to Improve Coding Accuracy for Better Revenue Cycle

Reliable Data for Financial Planning: Every revenue decision depends on data, and that data originates from coding. Accurate codes produce reliable analytics for forecasting, service line profitability, and payor negotiations.

Validate coded outputs against clinical documentation to ensure data integrity across reporting systems.

Build financial reports based on validated, accurate coded information to support forecasting and payor negotiations.

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Expert coders bring essential context, interpreting nuances such as physician intent and complex case combinations that algorithms may overlook. The strongest results come from integrating machine precision with human judgment to ensure every claim is accurate, compliant, and audit-ready.

•

Strengthen documentation practices. Clear, complete documentation is the foundation of precise coding, and by extension, accurate reimbursements. Coders can only assign codes based on what’s documented, making collaboration between clinicians and coding teams essential.

Regular communication helps clinicians understand how their notes impact claim outcomes and compliance. Smart templates, structured prompts, and real-time feedback systems improve documentation quality without adding administrative burden. When clinical notes accurately reflect the care provided, coding becomes faster, clarifications drop, and the entire revenue cycle runs more efficiently.

•

Conduct regular coding audits. Audits go beyond compliance as they are essential for improving coding accuracy and financial performance. Routine internal and external reviews reveal recurring mistakes, outdated practices, and areas of undercoding or overcoding.

These insights should drive targeted training, workflow adjustments, and system-level improvements.

Meghann Drella, CPC, is a Senior Solutions Manager at Managed Outsource Solutions (MOS), and is responsible for practice and revenue cycle management in the Healthcare Division. She has a formal education in medical coding and billing and over 12 years of hands-on experience in the field. She holds a CPC certification with the American Academy of Professional Coders (AAPC). Meghann has a strong understanding of ICD-10-CM and CPT requirements and procedures, and regularly attends continuing education classes to stay up to date with any changes. www.managedoutsource.com

Regular audits also uncover trends across specialties or locations, helping organizations address root causes instead of isolated mistakes. By catching issues early, practices can reduce revenue leakage and maintain steady cash flow.

•

Track coding metrics to strengthen RCM. Clinical data quality indicators contribute to a well-functioning revenue cycle by uncovering hidden patterns and areas for improvement. Integrating coding metrics into revenue cycle analytics provides actionable insights for datadriven decision-making. Tracking denial rates, codingrelated rejections, and first-pass resolution times helps pinpoint where issues originate. With this visibility, teams can make timely corrections before revenue is affected.

Advanced analytics can even predict potential risks, enabling management to allocate resources more effectively. When coding accuracy becomes a measurable part of RCM strategy, it transforms from a back-end correction to a front-end advantage.

From Codes to Cash Flow Revenue cycle optimization doesn’t depend on one component of the medical billing process. It requires coordination across documentation, coding, submission, and follow-up, each step influencing the next. In this cycle, coding is the bridge that determines how efficiently claims move and how accurately revenue is captured. When coding quality improves, denials drop, administrative rework decreases, and reimbursements accelerate. Practices that prioritize code precision not only protect revenue but also strengthen compliance, efficiency, and trust across their entire financial ecosystem.

Select the Medical Coder who completed 36 CEUs and webinars this year — FREE with their BC Advantage magazine subscription. www.billing-coding.com

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OPTIMIZING FRONT DESK MANAGEMENT IN MEDICAL PRACTICES The front desk is the operational nerve center of any medical practice, shaping patient perceptions and driving efficiency. Industry leaders know that excellence here requires strategic clarity, robust processes, and a culture of continuous improvement. Below, each section begins with a summary of expert recommendations, followed by expanded details for implementation.

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•

Appointment Scheduling and Confirmation: Implement scheduling software with color-coded calendars and automated reminders. Train staff to handle doublebooking scenarios and urgent requests without disrupting provider flow.

•

Insurance Verification and Copay Collection: Create a pre-visit verification checklist. Use payor portals or clearinghouses to confirm eligibility. Provide staff with scripts for explaining copays and outstanding balances to patients in a professional, empathetic manner.

•

Managing Phone Calls and Patient Inquiries: Establish a call triage system—urgent clinical calls to nurses, billing questions to the financial team, and general inquiries handled at the front desk. Document all calls in the EMR for continuity.

•

Maintaining Accurate Records in EMR: Train staff on data entry standards, including correct use of abbreviations and codes. Conduct monthly audits to catch and correct errors.

Advanced KPIs for Front Desk Excellence KPIs provide measurable benchmarks for efficiency and patient experience. Monitor them consistently, review trends, and use data to guide coaching and process improvements.

Precision in Job Descriptions and Role Clarity Clear job descriptions eliminate ambiguity, set expectations, and serve as a foundation for accountability and performance reviews. Define responsibilities, required skills, and measurable outcomes. Update these regularly to reflect changes in workflows, technology, and compliance requirements.

Precise job descriptions address: •

Patient Check-In/Check-Out: Train staff to greet patients warmly, verify identity, and confirm appointment details. At check-out, ensure follow-up appointments are scheduled, provide clear instructions, and confirm payment or billing arrangements. Use scripts to maintain consistency.

From a supervisor-to-direct report perspective, clearly defined KPIs are essential for fostering a transparent and effective working relationship. When supervisors communicate KPIs with clarity, direct reports understand exactly what is expected of them, removing ambiguity and aligning individual goals with the broader objectives of the medical practice. This clarity empowers staff to take ownership of their responsibilities, and supervisors can offer targeted feedback based on objective data rather than subjective impressions.

Regularly reviewing KPIs together creates opportunities for constructive dialogue, celebrating successes, and identifying areas for growth. Supervisors can use KPI trends to recognize top performers, provide tailored coaching, and address challenges promptly before they impact patient care or operational flow. For direct reports, knowing that their performance is measured against fair, consistent benchmarks builds trust and motivation; it also encourages a culture of continuous improvement, as employees see how their actions contribute to practice-wide outcomes.

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Ultimately, clear KPIs serve as a foundation for accountability and professional development. They enable supervisors to set actionable goals, track progress, and support their teams in delivering exceptional patient experiences. When everyone is aligned on what matters most, the front desk functions as a high-performing unit, driving both efficiency and satisfaction for patients and staff alike.

Example KPIs for a front desk position: •

Call Answer Rate: Track daily and weekly performance. If rates drop, analyze peak call times and adjust staffing or implement call queue technology.

•

Appointment Accuracy: Audit schedules weekly for errors. Use double-confirmation protocols for complex appointments (e.g., multi-provider visits).

•

Patient Wait Time: Measure from check-in to provider encounter. If wait times exceed benchmarks, review provider scheduling patterns and patient flow bottlenecks.

•

Insurance Verification Completion: Aim for 100% verification before appointments. Use dashboards to flag incomplete verifications and assign follow-up tasks.

•

Copay Collection Compliance: Track collection rates and train staff on handling objections. Consider offering multiple payment options (card, mobile pay) to improve compliance.

Elite Hiring Practices: Building a World-Class Front Desk Team A clear, structured hiring approach begins with a welldefined plan that outlines the essential qualities and competencies needed for front desk success. This plan should identify not only the technical skills required such as proficiency with scheduling software and accurate data entry, but also the attitudes, adaptability, and cultural fit that align with the medical practice’s mission and values. By starting with a comprehensive hiring blueprint, practices can systematically evaluate candidates using multiple methods: structured interviews with behavioral questions, rigorous reference checks, and practical assessments that simulate real-world scenarios.

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Research in healthcare administration consistently shows that organizations with formalized hiring plans and standardized interview processes experience lower turnover and higher employee engagement. For example, incorporating cultural fit assessments and scenario-based evaluations has been linked to improved team cohesion and better patient service outcomes. Establishing clear criteria and benchmarks from the outset enables hiring managers to objectively compare candidates and select those most likely to thrive in a dynamic, patient-centered environment.

In summary, a structured approach to hiring ensures that every step, from crafting job descriptions to onboarding, is aligned with the practice’s overall goals. This methodical planning reduces errors, supports compliance, and builds a front desk team that not only meets operational needs but also delivers exceptional patient experiences. When hiring is approached as a strategic process rather than a series of ad hoc decisions, medical practices are better positioned to identify and retain top talent.

Elite hiring practices: •

Structured Interviews: Include behavioral questions like, “Describe a time you handled an upset patient. What steps did you take?” Role play scenarios to assess communication skills.

•

Reference Checks: Ask previous employers about punctuality, reliability, and ability to handle stress. Request examples of how the candidate contributed to team success.

•

Work History Verification: Confirm employment dates and roles. Probe for gaps and ask candidates to explain transitions.

•

Cultural Fit Assessment: Share your practice’s mission and values during interviews. Ask candidates how they would contribute to a positive patient experience.

•

Practical Skills Assessment: Test candidates on scheduling software, data entry accuracy, and handling mock phone calls to gauge real-world performance

Written SOPs: The Blueprint for Consistency and Compliance

•

Handling Cancellations and No-Shows: Define policies for fees, rebooking, and follow-up communication.

Automate reminders to reduce no-shows.

Comprehensive, step-by-step instructions within written SOPs are essential for minimizing errors and empowering employees at the front desk. When every process is broken down into clear, sequential steps—from verifying insurance details to managing patient check-outs—staff can follow a consistent approach each time, which greatly reduces the risk of mistakes and ensures that critical compliance requirements are always met. These detailed instructions eliminate guesswork, making it easier for new hires to get up to speed and for seasoned team members to refresh their knowledge as needed.

•

Communication Standards: Include tone guidelines, escalation protocols, and sample scripts for common scenarios (e.g., billing inquiries, appointment changes).

Moreover, having well-documented SOPs fosters a collaborative environment where all team members can contribute to process improvement. When procedures are clearly written and accessible, staff can identify inefficiencies or suggest enhancements, helping the practice stay agile and responsive to changes in regulations or patient needs. Managers benefit as well, as they can implement small updates or policy improvements directly in the SOPs and instantly communicate these changes to the entire team. This ensures everyone is working with the most current information, reducing confusion and maintaining alignment across the practice.

Importantly, step-by-step SOPs boost employee confidence and engagement. When staff know exactly what is expected of them and have reliable resources to guide their actions, they feel supported and valued by the organization. This sense of security not only improves performance but also contributes to higher job satisfaction and retention.

Ultimately, detailed and regularly updated SOPs are a cornerstone of both operational excellence and a positive workplace culture.

•

•

Weekly meetings keep the team aligned, address challenges, and reinforce accountability. They should be structured, time-bound, and focused on actionable outcomes. In addition to group meetings, individual sessions between managers and direct reports are essential for fostering a supportive and growth-oriented environment within the medical practice. Regular one-onone feedback sessions ensure that employees feel valued, receive personalized guidance, and are more likely to invest their effort in the organization’s success. When staff have opportunities for direct communication with leadership, it enhances engagement and demonstrates that their contributions matter. Meanwhile, team meetings provide a forum for open group discussions, keeping everyone informed about updates, new processes, and changes in policy, while also allowing questions and clarifications in a collaborative setting. These discussions not only reinforce shared accountability but also strengthen teamwork, ultimately benefiting patient care by ensuring the front desk operates smoothly and efficiently.

Successful team meetings focus on: •

Agenda: Review KPIs, discuss workflow issues, share updates on policy changes, and recognize achievements.

•

Appointment Scheduling Protocols: Include steps for confirming provider availability, handling cancellations, and managing urgent requests.

Format: Limit to 15–30 minutes. Use a consistent structure: metrics challenges solutions action items.

•

Insurance Verification Workflows: Document payorspecific requirements and escalation steps for unresolved issues.

Engagement: Rotate facilitators to empower staff.

Encourage open dialogue and solicit feedback on SOPs and workflows.

•

Follow-Up: Document decisions and assign responsibilities. Review progress at the next meeting.

Written SOP examples: •

Weekly Team Meetings: Driving Alignment and Engagement

Patient Intake and Check-out Processes: Provide checklists for collecting forms, signatures, and payments.

Include scripts for explaining next steps.

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Communication Excellence: Office Manager and Front Desk Synergy Strong communication between the office manager and front desk team ensures smooth operations. Use daily huddles, feedback loops, and written updates to maintain clarity and prevent surprises.

Clear communication in the workplace provides numerous advantages beyond operational efficiency.

When information is shared openly and consistently, misunderstandings are minimized, and expectations are clearly defined. This not only helps each team member understand their role and responsibilities but also fosters trust and transparency across all levels of the organization.

Open lines of communication ensure that issues are addressed proactively, which reduces the likelihood of conflicts and errors that could disrupt patient care or workflow.

One of the most significant benefits of clear communication is its impact on employee retention and turnover rates.

When staff members feel informed, heard, and supported through regular updates, feedback opportunities, and transparent decision-making, their job satisfaction increases. Employees who know what is expected of them and receive timely feedback are more likely to feel valued and engaged in their work. This engagement leads to higher morale, a stronger sense of belonging, and greater loyalty to the organization. As a result, turnover rates decrease because employees are less likely to seek opportunities elsewhere when they feel connected, respected, and part of a collaborative team. In turn, reduced turnover saves the organization time and resources that would otherwise be spent on recruiting, hiring, and training new staff, allowing the practice to maintain continuity and deliver consistent, high-quality service to patients.

•

Feedback Loops: Create anonymous suggestion channels or regular feedback sessions to encourage staff input.

•

Written Updates: Use email or internal messaging for policy changes and reminders. Require acknowledgment to confirm receipt.

•

No Surprises Policy: Communicate changes before they impact workflow or patient experience. Encourage proactive updates from all team members.

Industry Expert Commentary: The Path to Front Desk Excellence Front desk optimization is a continuous process requiring investment in people, processes, and technology. Practices that prioritize accountability, learning, and patient-centered care consistently outperform their peers.

Optimizing your front desk is not a one-time project, it’s a continuous journey. The most successful practices invest in their people, processes, and technology. They foster a culture of accountability, learning, and patient-centered care. By applying these expert strategies, your front desk will not only run efficiently but will also become a source of pride and competitive advantage for your practice.

Matt Kolinski, DO, is an Associate Management Consultant with DoctorsManagement. He has extensive experience spanning 20+ years as a practicing physician and entrepreneur. Dr. Matt has a passion for re-engineering the business of healthcare. With his hands-on experience in medicine, he combines his expertise and passion to perform practice assessments and feasibility studies and assist with practice start-ups.

Effective communication offers: •

Daily Huddles: Hold 5-minute check-ins to review priorities, address concerns, and share updates.

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TIME-BASED MEDICAL CODING Time-based coding is an essential concept in medical coding and billing that applies when the amount of time a provider spends with a patient determines the level of service reported. Understanding how to properly document and report time-based services helps ensure accurate reimbursement and compliance with payor guidelines.

What Is Time-Based Coding?

Time-based coding is used when time becomes the controlling factor in selecting a CPT code. This typically applies when more than 50% of the visit is spent on counseling and/or coordination of care, or when time is explicitly listed as a defining factor in the code descriptor.

Common types of services that use time-based coding include: •

Evaluation and Management (E/M) visits

•

Prolonged services

•

Critical care services

•

Behavioral health services

•

Care management services

When Can You Use Time as the Key Factor?

Time can be used to select a code when the medical record clearly documents: •

Total time spent with the patient

•

Specific activities performed during that time

•

That at least 50% of the time was spent counseling or coordinating care (if required)

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For 2021 and later office/outpatient E/M codes, time includes both face-to-face and non-face-to-face work performed by the provider on the date of service, such as: •

Reviewing records

•

Ordering tests

•

Coordinating care

•

Documenting in the medical record

Time-Based Coding for E/M Services With current office/outpatient E/M guidelines, code selection can be based on total time or Medical Decision

Making (MDM).

Example of acceptable documentation:

Each CPT code has a defined time range. For example: •

99202: 15–29 minutes

•

99212: 10–19 minutes

•

99203: 30–44 minutes

•

99213: 20–29 minutes

“Total time spent on today’s visit: 42 minutes, including reviewing labs, counseling the patient on treatment options, and documenting the encounter.”

•

99204: 45–59 minutes

•

99214: 30–39 minutes

•

99205: 60–74 minutes

•

99215: 40–54 minutes

Common Time-Based Coding Mistakes to Avoid Medical coders should watch for these common errors:

When coding by time, the total documented time must fall within the published time range for the selected code.

•

Failing to document the total time Not showing how the time was spent

Prolonged Services and Time

• •

Using the time when MDM should have been used

•

Rounding time incorrectly

•

Reporting prolonged service codes without meeting time thresholds

Prolonged service codes may be reported when the physician’s time extends beyond the maximum time associated with the primary E/M code.

Important points for prolonged services: •

Must clearly exceed the typical time for the base code.

•

Documentation must support the medical necessity for the extended time.

•

Different payors have different rules for reporting prolonged services.

Practical Time-Based Coding Tips Here are helpful tips for accurate time-based coding: •

Always verify current CPT and payor-specific time thresholds.

•

Look for explicit documentation of total time.

•

Critical care codes are always time-based and require continuous attendance by the provider.

Confirm whether time or MDM is being used to select the code.

•

Make sure counseling and coordination times are clearly described.

Critical care time:

•

Avoid assumptions if time is not clearly documented.

Critical Care and Time-Based Coding

•

Includes time spent directly at the patient’s bedside or unit

Why Time-Based Coding Matters

•

Cannot include time spent on separately reportable procedures

•

Proper reimbursement

•

Must be clearly documented in the medical record

•

Reduced audit risk

•

Clear communication of provider’s work

•

Compliance with Medicare and commercial payor rules

Medical Coding Critical Care Documentation Requirements for Time-Based Services Strong documentation is essential for compliant timebased coding.

The provider should document: •

Start and stop times (when required)

•

Total time spent on the date of service

•

Description of the work performed

•

Amount of time spent counseling or coordinating care (when applicable)

Accurate time-based coding ensures:

Time-based coding, when done correctly, reflects the true complexity and effort of patient care and supports the integrity of medical billing and reimbursement.

Janine Mothershed is the founder and CEO of Coding Clarified, an innovative online medical coding school committed to transforming lives through flexible, high-quality career training. A Certified Professional Coder (CPC) and licensed AAPC instructor, Janine brings over a decade of experience in healthcare administration, medical coding, and workforce development. https://codingclarified.com

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Reviews

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Reviews

The new CEU pages are a game-changer.

Where: www.billing-coding.com/ceus.cfm Your Price: FREE with magazine subscription Publisher: Billing-Coding, Inc The updated BC Advantage CEU pages make completing CEUs easier and more enjoyable than ever. The layout is clean, intuitive, and incredibly easy to follow—especially during webinars. Everything flows smoothly, so you can focus on learning instead of clicking around.

One of the biggest improvements is how simple it is to search past, current, and even unused CEUs. No more wondering what you’ve already completed or what still counts. Your CEU history, certificates, and available credits are all clearly organized in one place.

Whether you’re watching a live webinar or catching up on on-demand CEUs, the experience feels faster, clearer, and far more engaging. It’s obvious these pages were designed by people who understand how busy medical coding and billing professionals really are.

Completing CEUs has never felt this organized—or this easy.

JustCoding’s Practical Guide to Coding Management, Second Edition Where: https://hcmarketplace.com/justcoding-practical-guide-coding-management Your Price: $165.00 Publisher: Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS ICD-10 has been fully implemented for more than three years, fundamentally changing how coding managers assess the productivity of coders, the quality of their work, the number of coders available in the workforce, the need for coder education and training, and the need for auditing. Coding managers must continue to update their strategies to keep up with ever-changing code and regulation updates.

JustCoding’s Practical Guide to Coding Management, Second Edition, gives coding managers the latest benchmarks, standards, and tips so they can ensure they’re running an effective department. It gives them strategies to retain coders, as well as provides best practices on how to balance internal and outsourced coders and how to manage on-site and remote staff.

To help managers find a balance between coder productivity and accuracy, this book provides detailed findings from a recent nationwide coding productivity survey. The survey provides insight from coding professionals on the types of facilities they work in, their everyday challenges, and their facility’s expectations for coding productivity and accuracy.

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Mastering the FY 2025 ICD-10-CM Code and Guideline Update

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Basics of Pain Management: Chronic Pain Medical Billing and Coding

Navigating Compliance: The Importance of Self-Reporting

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