Key Takeaways Medical claim denials cluster into a small number of categories — most practices are dealing with the same types, even if the specific codes and circumstances differ Coding-related denials are the most prevalent and most preventable; they trace to claim elements that don’t align with each other or with payer rules Medical necessity […]
Orthopedic Billing Codes: The Errors Costing Surgical Practices the Most
Key Takeaways Global period exceptions require specific modifiers, and each carries a documentation requirement that, when unmet, turns a legitimate claim into a denial or a compliance flag. The multiple procedure reduction rule applies automatically to multi-procedure surgical cases; correct sequencing and modifier 51 exemptions still have to be managed manually. Modifier 22 is warranted […]
What Is a Clean Claim Rate? Benchmarks, Calculations, and What the Number Won’t Tell You
Key Takeaways A clean claim rate measures the percentage of claims accepted by the payer on first submission, without rejection or request for additional information Industry benchmarks, including those referenced by HFMA, put the target for high-performing operations at 98% — most practices land between 85% and 95%, and that gap has a direct dollar […]
Cardiology Billing: The Coding Errors That Keep Costing Practices Money
Key Takeaways Catheterization CPT code selection depends on whether the procedure was diagnostic or interventional and which components were performed — and both have to be right. Errors in this code family are among the most audited patterns in cardiology billing. CPT 93306 requires 2D imaging, M-mode, spectral Doppler, AND color flow Doppler — all […]
Chiropractic Billing Codes: How CPT Selection, Modifiers, and Diagnosis Alignment Drive Denials
Key Takeaways The CPT code for chiropractic manipulative treatment is determined by the number of spinal regions documented as treated — a mismatch between the code and the clinical record is one of the most consistent sources of denials. ICD-10 diagnosis codes must reflect the specific regions being treated; vague or non-specific codes leave claims […]
The Billing Gap Between Telehealth and In-Office Mental Health Visits
Key Takeaways Telehealth and in-office mental health visits require different place-of-service codes, and submitting the wrong one is one of the most common sources of avoidable denials. Modifier requirements vary by payer — and modifier rules for audio-video telehealth have shifted over time, so assumptions based on older workflows may no longer be accurate. Documentation […]
How to Use a Medical Claim Scrubber: A Step-by-Step Walkthrough
Key Takeaways A medical claim scrubber reviews CPT codes, modifiers, diagnosis codes, and claim structure before submission to flag errors that lead to denials Different specialties produce different types of claim errors — the same pre-submission review process surfaces different issues depending on the claim context AI-powered claim scrubbers identify relationships between coding elements that […]
Colonoscopy Billing: When Screening Becomes Diagnostic
Key Takeaways A colonoscopy that begins as a screening procedure can become diagnostic mid-procedure, and that shift carries significant billing and reimbursement implications that many GI practices handle inconsistently. Medicare and most commercial payers require different codes, modifiers, and documentation depending on how a procedure is classified, and errors in that classification are among the […]
Toxicology Lab Billing: Why Payer Scrutiny Is Getting Harder to Navigate
Key Takeaways Payer scrutiny of toxicology lab billing has intensified significantly, with Medicare Administrative Contractors and commercial insurers applying stricter medical necessity and documentation standards. Definitive and presumptive drug testing require distinct coding approaches, and errors in distinguishing between them are among the most common sources of toxicology claim denials. Local Coverage Determinations vary by […]
PGM Billing Launches AI-Powered Medical Claim Scrubber Through RevAIant Partnership
Key Takeaways PGM Billing has partnered with RevAIant to introduce AI-driven claim scrubbing capabilities The solution helps identify coding errors and denial risks before claims are submitted Earlier validation supports stronger clean-claim rates and fewer downstream corrections The AI-powered medical claim scrubber provides immediate feedback without requiring PHI Billing teams gain greater confidence in claim […]