Radiology billing is different from most specialties because one imaging study is usually split into two billable parts: the technical component (equipment, staff, and supplies) and the professional component (the radiologist’s interpretation and report). Who owns the equipment and who reads the study…
Medicaid Credentialing: What’s Different From Commercial Payers
Medicaid credentialing is really two processes. First, the provider enrolls with the state Medicaid agency. Then the provider is credentialed separately with each Medicaid managed care organization (MCO) the practice wants to see patients from. Commercial credentialing is one payer, one process. Medicaid…
Physician Billing Services: What to Look for in a Vendor
Physician billing services are outside companies that handle some or all of a practice’s revenue cycle: charge entry, coding, claim submission, payment posting, denial follow-up, and patient billing. The right vendor can cut days in A/R and recover denials your team never had…
DNFB (Discharged Not Final Billed): What It Means and How to Fix It
DNFB stands for discharged not final billed. It’s the set of patient accounts where the patient has been discharged and care is complete, but a final claim hasn’t been produced yet. Money in DNFB has been earned but can’t be collected, because nothing…
Revenue Codes Explained: A Practical Reference for Billing Teams
Revenue codes are four-digit codes reported on the UB-04 (CMS-1450) institutional claim that tell the payer which department or type of service a charge came from, such as pharmacy, operating room, or emergency room. They’re maintained by the National Uniform Billing Committee (NUBC)…
What Is Prior Authorization? The Basics Before the Denial Workflow
What is prior authorization? It is the process where a health plan has to approve a service, procedure, or drug before the patient gets it, or the plan won’t pay. It’s sometimes called pre-authorization or pre-certification. For a physician practice, it’s an administrative…
CPT Code 99213 Explained: When to Use It and How to Bill It
CPT 99213 is an office or outpatient visit for an established patient that requires low medical decision making (MDM), or at least 20 minutes of total time on the date of the encounter. It’s one of the most-billed codes in outpatient medicine, so…
No Surprises Act: A Compliance Checklist for Physician Practices
The No Surprises Act took effect on January 1, 2022, and it affects physician practices in two main ways. You have to give uninsured and self-pay patients a good faith estimate before scheduled care. And in situations the law covers, you can’t bill…
Pass-Through Billing Explained: What It Is and When It Applies
Pass-through billing happens when a physician practice bills for a diagnostic test or lab service performed by an outside supplier as though the practice performed it in-house. It is one of the more common ways a small practice ends up on the wrong…
EDI 837: What It Is and How Claims Actually Get Transmitted
Every electronic medical claim submitted in the United States runs through the same standardized format behind the scenes, whether the practice knows it or not. Understanding what that format actually does helps make sense of where claims problems come from. What EDI 837…