• 9:00 AM - 6:00 PM ET
Contact Us
Near Me
Medientsky Billing - Elevating Healthcare Revenue
Get Free Billing Audit

Author name: Ariab

Coding

Radiology Medical Billing Services | Complete Guide

/

Radiology medical billing is the process of coding, submitting, tracking, and collecting payment for imaging services. It involves more than assigning a CPT code. Practices also have to manage prior authorization, professional and technical components, modifiers, payer rules, medical necessity, denials, and accounts receivable. This guide explains the full radiology billing process and the areas that can directly affect reimbursement. What Is Radiology Medical Billing? Radiology medical billing turns diagnostic and interventional imaging services into insurance claims and manages those claims until they are paid or otherwise resolved. The process connects clinical documentation with CPT and ICD-10-CM coding, payer requirements, authorization rules, claim submission, payment posting, and denial follow-up. For a radiology practice, billing may involve services such as: The billing requirements can vary based on the procedure, payer, place of service, provider, and whether the professional or technical component is being reported. Why Is Radiology Billing Different From General Medical Billing? Radiology billing has several layers that are not always present in a standard office visit. The same imaging study may involve a facility performing the scan and a radiologist interpreting the images. Advanced imaging may also require prior authorization before the patient can receive the service. This makes radiology medical billing highly dependent on accurate coordination between the ordering provider, imaging facility, radiologist, billing team, and insurance payer. A billing team may need to confirm: How Does Radiology Medical Billing Work? A strong radiology billing workflow starts before the imaging study takes place. Authorization and eligibility should be checked early, followed by documentation and coding review. After the claim is submitted, the billing team monitors payer responses, posts payments, and works on any rejected or denied claims. The typical workflow includes: An error at any stage can create additional work later. For example, an authorization problem discovered after the procedure may be much harder to resolve than one identified before scheduling. Radiology Prior Authorization Requirements Prior authorization is an important part of radiology revenue cycle management because many payers require approval for selected advanced imaging services. CT, MRI/MRA, PET, and nuclear cardiology procedures may be subject to authorization depending on the payer and plan. Practices should verify requirements before scheduling rather than assuming every imaging service is covered without approval. Payers use prior authorization to review whether certain services meet their coverage and clinical criteria. UnitedHealthcare’s current radiology program, for example, lists CT, MRI/MRA, PET, and nuclear cardiology among advanced outpatient imaging services that may require prior authorization. Its 2026 updates also show that specific CPT codes can be added to these programs over time. A practical authorization workflow should include: Missing authorization can result in a denied claim. In some cases, the provider may have limited ability to recover the expected reimbursement after the service has already been performed. Authorization also does not guarantee payment. Eligibility, coverage, medical necessity, coding, documentation, and other claim requirements can still affect the final outcome. What Are Professional and Technical Components in Radiology? The professional component generally represents the radiologist’s work in interpreting an imaging study and preparing the report. The technical component represents the resources required to perform the study, including equipment, staff, supplies, and facility resources. When different entities provide these components, they may be billed separately under applicable rules. For example, an imaging center may perform an MRI while a radiologist in another location interprets the images. The facility may bill the technical component, while the radiologist or appropriate entity bills the professional component. The distinction matters because incorrect component billing can create claim errors and payment problems. Which CPT Codes Are Used in Radiology Billing? CPT codes identify the medical service or procedure performed, while ICD-10-CM codes describe the diagnosis or clinical condition supporting the service. Radiology billing teams need to make sure the selected codes accurately reflect the documentation and the actual service performed. Common Radiology CPT Code Examples CPT Code  Example Service What the Billing Team Should Review 71046 Chest X-ray, 2 views Documentation, views performed, component billing, and applicable payer rules 74177 CT abdomen and pelvis with contrast Medical necessity, contrast documentation, authorization, and component billing 70553 MRI brain without and with contrast Authorization, documentation, contrast use, and professional/technical reporting These examples are intended to illustrate how specific radiology services are represented in CPT. They should not replace the current CPT code set or payer-specific guidance. Radiology coding also changes over time. The AMA’s current CPT information shows continued updates for new imaging technologies and services. The CPT 2027 release includes new and revised radiology codes and a new table for head and neck magnetic resonance angiography. Which Modifiers Are Used in Radiology Medical Billing? Modifiers provide additional information about a service and can affect how a claim is processed. In radiology, they are particularly important when professional and technical components are billed separately or when a procedure has circumstances that require additional clarification. Common modifiers include: CMS also recognizes modifiers such as XE, XP, XS, and XU for appropriate NCCI circumstances. These modifiers should be supported by the actual clinical situation. They should not be added simply to bypass a coding edit. How Is Radiology Reimbursement Calculated? For services paid under the Medicare Physician Fee Schedule, reimbursement is based on relative value units, geographic adjustments, and a conversion factor. The main RVU categories are Work RVU, Practice Expense RVU, and Malpractice RVU. CMS applies geographic practice cost indexes to these components before applying the conversion factor. In simplified terms: Payment = Geographically adjusted RVUs × Conversion Factor The Work RVU reflects the physician’s time, effort, and clinical intensity. The Practice Expense RVU reflects resources such as staff, equipment, supplies, and facility costs. The Malpractice RVU represents professional liability costs. The actual Medicare formula is more detailed because each component receives its own geographic adjustment. CMS updates the Physician Fee Schedule and its underlying values over time, so billing teams should use the applicable year’s data rather than relying on outdated reimbursement figures. What Is AI-Assisted Diagnostic Imaging? AI-assisted imaging uses software to

Orthopedic medical billing and coding services
Revenue Cycle

Complete Guide to Orthopedic Medical Billing Services

/

Orthopedic medical billing involves more than submitting claims after a patient visit. Orthopedic practices handle office evaluations, imaging, injections, fracture care, surgeries, postoperative visits, and other procedures that each have specific coding and billing requirements. Accurate documentation, correct CPT and ICD-10 coding, appropriate modifiers, and consistent follow-up all play a role in getting claims processed correctly. Why Is Orthopedic Medical Billing Different? Orthopedic billing can be complex because the specialty includes many procedures, surgical services, diagnostic services, and follow-up visits. A single patient may receive several services during one episode of care, and each service must be reported according to the applicable coding and payer rules. Orthopedic practices also need to understand global surgery rules, NCCI edits, procedure-specific requirements, and modifiers. The American Academy of Orthopaedic Surgeons provides dedicated coding and reimbursement resources for orthopedic professionals, while CMS publishes the rules and coding guidance used for Medicare claims. Common Orthopedic Services That Require Billing Orthopedic medical billing may cover a wide range of services depending on the practice and its specialties. Common examples include: Office evaluation and management visits Fracture and dislocation treatment Joint injections Arthroscopy Joint replacement procedures Tendon and ligament procedures Casting and splinting Musculoskeletal imaging Postoperative visits Physical medicine and rehabilitation services Treatment of sports-related injuries Each service needs to be supported by appropriate documentation and reported using the correct codes. How Does Orthopedic Medical Billing Work? Orthopedic medical billing usually follows a series of steps from patient registration to final payment. Each step affects the next, so an error during registration or coding can create problems later in the claims process. Patient Registration and Insurance Verification The process starts with collecting accurate patient and insurance information. The billing team verifies coverage, eligibility, benefits, and other payer requirements before services are provided when possible. This step can help identify coverage limitations, authorization requirements, and incorrect insurance information before a claim is submitted. Documentation and Medical Coding The provider’s documentation is reviewed to determine the appropriate diagnosis and procedure codes. Orthopedic coding may involve ICD-10-CM diagnosis codes, CPT procedure codes, HCPCS codes, and applicable modifiers. The code selection should reflect the services actually performed and documented. Orthopedic coding resources from AAOS cover CPT codes, ICD-10, E/M services, modifiers, and other reimbursement topics. Claim Submission Once the claim has been coded and reviewed, it is submitted to the appropriate payer. Claims should contain accurate patient information, provider details, diagnosis codes, procedure codes, modifiers, and other required information. Clean claims reduce the need for corrections and resubmissions. Payment Posting After the payer processes the claim, payments and adjustments are posted to the patient’s account. The billing team compares the payer’s explanation of benefits with the expected reimbursement and identifies balances that need additional attention. Denial Management and A/R Follow-Up Not every claim is paid on the first submission. Denials may result from coding issues, missing information, eligibility problems, authorization requirements, payer edits, or documentation concerns. The billing team reviews the reason for the denial, corrects the underlying issue when appropriate, submits an appeal or corrected claim when permitted, and follows up on outstanding accounts. Understanding Global Surgery in Orthopedic Billing Global surgery rules are particularly important for orthopedic practices because many orthopedic procedures involve postoperative care. Medicare uses global surgery indicators to identify the postoperative period associated with a procedure. CMS identifies 000, 010, and 090 global surgery indicators. A 000-day period generally applies to procedures where the related preoperative and postoperative work is included on the procedure day. A 010-day period includes the procedure day and a 10-day postoperative period. A 090-day period applies to major surgery and includes a 1-day preoperative period and a 90-day postoperative period. Understanding the applicable global period helps billing teams determine when a postoperative service is included in the surgical payment and when a service may be separately reportable. Orthopedic Billing Modifiers Modifiers provide additional information about how or why a service was performed. They are especially important in orthopedic medical billing because the same procedure code can have different reporting requirements depending on the circumstances. Common modifiers that orthopedic practices may encounter include: 1)  Modifier 24: Unrelated E/M service during a postoperative period 2) Modifier 25: Significant, separately identifiable E/M service 3) Modifier 57: Decision for surgery 4) Modifier 58: Staged or related procedure during the postoperative period 5) Modifier 78: Unplanned return to the operating or procedure room 6) Modifier 79: Unrelated procedure during the postoperative period 7) Modifier 59: Distinct procedural service when applicable These modifiers should only be used when the documented clinical circumstances support them. CMS specifically states that modifiers should not be added simply to bypass an NCCI edit. Common Orthopedic Billing Problems Orthopedic practices can face several billing challenges during the claim lifecycle. Some common issues include: Incorrect CPT or ICD-10 coding Missing or unsupported modifiers Incomplete clinical documentation Incorrect patient or insurance information Authorization problems NCCI procedure-to-procedure edits Global surgery billing errors Unresolved claim denials Delayed A/R follow-up Incorrect payment posting NCCI procedure-to-procedure edits are designed to prevent inappropriate payment when certain code combinations should not be reported together. CMS provides current NCCI guidance and edit files that billing teams can use when reviewing claims. How Can Orthopedic Practices Improve Their Billing? Improving orthopedic medical billing starts with consistent processes. Practices can review their billing workflow and identify where claims are most often delayed or denied. Useful steps include: Verify insurance information before appointments and procedures. Review documentation before finalizing codes. Use current CPT and ICD-10 coding resources. Check applicable NCCI edits before claim submission. Review modifiers carefully instead of applying them automatically. Monitor claims after submission. Track recurring denial reasons. Follow up on unpaid claims consistently. Review accounts receivable by payer and aging. Update billing procedures when payer or CMS rules change. Regular review can help practices identify patterns instead of treating every denial as an isolated issue. What Should You Look for in an Orthopedic Medical Billing Service? The right orthopedic medical billing service should understand the specialty rather than treating orthopedic

Top private medical billing companies in the US for healthcare practices
Revenue Cycle

Top Private Medical Billing Companies in the US

/

Choosing a medical billing company is an important decision for any healthcare practice that wants better control over claims, payments, and accounts receivable. This guide covers private medical billing companies in the US, what they offer, who they may be a good fit for, and what to consider before signing a contract. The demand for outsourced billing continues to grow. Grand View Research estimates that the U.S. medical billing outsourcing market was worth $6.95 billion in 2025 and could reach $17.69 billion by 2033. Why Are Medical Billing Services in Demand? Medical billing has become more difficult to manage as payer requirements, coding rules, claim volumes, and administrative responsibilities continue to grow. Outsourcing allows healthcare practices to bring in billing specialists without building a large internal revenue cycle team. Claim denials are another reason practices look for outside support. Recent research has reported that around 12% of initial claims can be denied, although the rate varies depending on the payer, provider, specialty, and type of claim. For a busy practice, even a small percentage of unpaid claims can create a large amount of work. How We Evaluated These Companies We looked at the services each company publicly offers, including medical billing, revenue cycle management, coding, denial management, credentialing, claims processing, and related healthcare technology. We also considered the types of healthcare organizations each company says it serves. The “Best for” descriptions are included to make the list easier to understand. They are not independent rankings or claims that one company is better than another. Top Private Medical Billing Companies in the US The companies below serve different parts of the healthcare market. Some focus more on independent practices, while others provide technology or revenue cycle services for larger physician groups and health systems. Medientsky Billing Best for: Practices looking for end-to-end revenue cycle support Medientsky Billing provides medical billing and revenue cycle management services for healthcare providers across the US. Its services include medical billing and claims processing, medical coding, denial management, credentialing, billing audits, and EHR/EMR integration. The company says its billing specialists support more than 30 medical specialties. Its RCM approach covers several stages of the billing process, from patient intake through payment and follow-up. For practices dealing with recurring denials, aging A/R, or multiple billing responsibilities, having one team manage several parts of the revenue cycle can make day-to-day operations easier. BillingParadise Best for: Small and mid-sized practices with broader RCM needs BillingParadise provides front-end, middle, and back-end revenue cycle services. Its offerings include eligibility verification, prior authorization, medical coding, claims submission, payment posting, denial management, A/R follow-up, and credentialing. The company also says it works with more than 25 EHR systems and supports independent practices, group practices, and hospitals. For a practice that wants to outsource several billing functions rather than manage separate vendors for coding, claims, and A/R, this type of service model may be worth considering. Medwave Billing & Credentialing Best for: Practices that need billing and credentialing support Medwave provides medical billing and credentialing services for healthcare providers in the US. Combining these services can be useful for practices that need help with both ongoing claims and getting providers enrolled with insurance payers. For providers searching for a medical billing company in New York, it is also worth checking whether a billing company has experience with the payers and requirements relevant to the local market. Before choosing a company, ask which payers it regularly works with and whether credentialing is handled by the same team responsible for billing. AdvancedMD Best for: Independent private practices wanting billing and practice technology together AdvancedMD offers medical billing software along with managed revenue cycle services. Its RCM services include claims management, payment posting, denial and collection support, reporting, and account management. The company positions its services around independent physicians and private practices. It also offers EHR and practice management technology, allowing clinical, administrative, and financial workflows to work together. This can be useful for practices that prefer an integrated system instead of moving information between several separate platforms. athenahealth Best for: Growing practices and organizations with more complex billing needs athenahealth provides revenue cycle services covering areas such as registration, insurance verification, authorization management, coding, claim submission, payment posting, denial resolution, and reporting. Its athenaIDX product is designed for larger and more complex organizations, while athenaOne combines EHR, practice management, and revenue cycle functions for other healthcare practices. For a growing organization, the ability to support both everyday billing and more complex revenue cycle operations can be an important consideration. R1 Best for: Health systems and large provider organizations R1 focuses on enterprise revenue cycle management and works with health systems, physician groups, and other healthcare organizations. Its services combine revenue cycle operations with technology, automation, analytics, and other financial management tools. R1 is therefore a different type of option from a smaller billing company that mainly works with independent physician practices. Larger organizations considering an enterprise provider should look closely at implementation, integration, reporting, and the level of support available. DrChrono Best for: Independent practices looking for an integrated EHR and billing setup DrChrono combines EHR, practice management, payments, medical billing, and revenue cycle tools in one platform. It also provides managed billing services. Its RCM services include eligibility verification, claims submission, payment posting, denial management, and A/R follow-up. DrChrono also says its managed RCM service includes certified billers and coders and provides reporting. For smaller practices, keeping clinical and financial workflows within one connected system can reduce the need to transfer information between different platforms. Coronis Health Best for: Healthcare organizations needing broader RCM support Coronis Health provides revenue cycle services covering medical billing, coding, credentialing, collections, and other financial operations. Its broader service model may be useful for organizations that need help across multiple parts of their revenue cycle rather than simply sending claims to insurance companies. Larger provider groups should also look at how a company handles reporting, system integration, implementation, and communication across different locations. eClinicalWorks Best for: Practices looking for

EMR system software for healthcare practices
EHR

What Is an EMR System? Top EMR Software List for Healthcare

/

An EMR (Electronic Medical Record) system is software that stores and manages a patient’s digital medical chart, including medical history, diagnoses, medications, allergies, clinical notes, lab results, and treatment information. It helps healthcare providers document visits, organize patient data, and manage clinical workflows electronically. Healthcare practices handle a huge amount of patient information every day. From medical histories and diagnoses to medications, lab results, treatment notes, and follow-up plans, keeping everything organized is essential for patient care and efficient operations. EMR systems replace paper-based medical charts with digital records that healthcare providers can access, update, and manage electronically. Modern platforms can also include scheduling, patient portals, telehealth, billing, reporting, and revenue cycle management tools. However, not every EMR is designed for the same type of healthcare organization. A solo physician, specialty clinic, and large hospital system can have very different requirements. This guide explains what an EMR system is, how it works, the different types of EMRs, key features to consider, popular EMR software, and how to choose the right system for a healthcare practice. What Is an EMR System? An EMR, or Electronic Medical Record, is the digital version of a patient’s medical chart maintained by a healthcare provider or practice. Instead of keeping patient histories, diagnoses, medications, treatment notes, and other clinical information in paper files, an EMR stores this information electronically. Providers can use an EMR to review a patient’s history, document encounters, monitor treatment progress, manage medications, and support clinical decision-making. According to the Office of the National Coordinator for Health Information Technology, an EMR is generally centered on the records maintained by an individual provider or practice, while an EHR has a broader focus and supports information exchange across healthcare organizations. In everyday healthcare conversations, however, the terms EMR and EHR are frequently used interchangeably. How Do EMR Systems Work? An EMR brings patient information into one digital environment. During a patient visit, a provider can review existing information and add new clinical data to the patient’s chart. Patient Information An EMR can store information such as: Having this information available electronically can make it easier for authorized providers and staff to review a patient’s history without searching through physical files. Clinical Documentation Providers can document patient encounters directly within the system. Depending on the software, they may have templates, electronic prescribing, specialty-specific documentation tools, order management, and clinical decision support. These tools can help standardize documentation while allowing providers to spend less time managing paper records. Scheduling and Practice Management Many modern EMR platforms go beyond clinical documentation. They may include appointment scheduling, online patient intake, patient communication, telehealth, billing integrations, reporting, and other practice management functions. This is one reason healthcare organizations should look beyond a simple feature checklist when comparing EMR systems. The software needs to fit the way the practice actually operates. Types of EMR Systems EMR systems can differ based on their specialty focus, hosting model, and level of customization. Understanding these differences can help healthcare organizations narrow down their options before comparing individual vendors. Specialty-Specific EMRs Specialty-specific EMRs are designed around the workflows and documentation requirements of particular medical specialties. For example, a behavioral health practice may need specialized mental health documentation and treatment workflows. An ophthalmology practice may require tools for eye examinations, while a cardiology practice may need different templates and diagnostic integrations. A specialty-focused EMR can reduce the need for extensive customization because many relevant workflows are already built into the system. Cloud-Based EMRs Cloud-based EMRs are hosted by the software provider and accessed through an internet connection. They can reduce the need for healthcare practices to maintain their own servers and may make software updates, backups, and remote access easier to manage. Many modern healthcare platforms, including athenahealth, eClinicalWorks, Practice Fusion, Tebra, and DrChrono, use cloud-based technology. On-Premise EMRs On-premise EMRs are installed and maintained on an organization’s own servers or infrastructure. This model can give organizations greater control over their technology environment. However, it can also require additional investment in hardware, maintenance, backups, security, and IT personnel. Large healthcare organizations with dedicated IT teams may consider this approach depending on their infrastructure and requirements. Customizable EMRs Customizable EMRs allow healthcare organizations to modify certain aspects of the system, such as templates, forms, workflows, reporting, user permissions, and other settings. Customization can be particularly useful for specialty practices or organizations with unique workflows. However, too much customization can increase implementation and maintenance requirements. Practices should focus on the changes they actually need rather than customizing every part of the system. Key Features to Look for in EMR Systems Not every EMR platform is built for the same type of healthcare organization. A small outpatient practice may have very different requirements from a large hospital system. Before choosing software, healthcare organizations should consider several important features. Ease of Use If an EMR is difficult to navigate, providers and staff may spend more time managing the software instead of focusing on patients. A clean interface, efficient documentation process, customizable templates, and simple navigation can make a significant difference in daily use. Interoperability Healthcare rarely happens in one location. Patients may see primary care providers, specialists, hospitals, laboratories, pharmacies, and other healthcare organizations. An EMR with strong interoperability capabilities can make it easier to exchange relevant health information between authorized users and systems. Security and Access Controls Patient information is sensitive. EMR software should include appropriate security controls, user permissions, authentication, audit capabilities, and other safeguards designed to protect health information. Healthcare organizations should also understand how the vendor handles data storage, backups, system access, and security monitoring. Billing and Revenue Cycle Integration For many practices, clinical documentation and billing are closely connected. The information captured during a patient encounter can affect coding, claims, reimbursement, and ultimately the practice’s revenue. An EMR that works effectively with billing and revenue cycle processes can reduce unnecessary manual data entry and improve the flow of information between clinical and administrative teams. Reporting and Analytics Healthcare organizations need more than patient

Mental health billing services for behavioral health practices
Process, Compliance

Mental Health Billing Services | Reduce Claim Denials

/

Mental health billing comes with a lot of moving parts. A therapy session or psychiatric visit may seem simple from the provider’s side, but getting that service paid can involve eligibility checks, authorization, documentation, coding, claim submission, and follow-up with the payer. A problem at any one of those stages can hold up payment. For behavioral health practices, this can become frustrating very quickly. A claim may be submitted correctly from the practice’s perspective but still come back unpaid because an authorization was missing, the patient’s coverage had changed, or the documentation did not support what was billed. This is where mental health billing services can make a difference. The work is not limited to sending claims. It also involves checking for problems before submission, keeping track of outstanding claims, working denials, and following up on payments that have not arrived. For psychologists, psychiatrists, therapists, counselors, and other behavioral health providers, having that process under control can take a significant amount of administrative work off the practice. Why Mental Health Claims Get Denied There is rarely just one reason for a mental health claim denial. Some problems start at the front desk, while others are discovered only after the claim reaches the payer. Here are some of the most common areas where problems occur. Eligibility and Coverage Issues A patient’s insurance coverage can change without the practice realizing it. The patient may have changed plans, lost coverage, reached a deductible, or have different benefits for behavioral health services than the practice expected. Verifying eligibility before the appointment gives the practice a chance to catch those issues before providing the service. The check should cover active coverage, benefits, deductible, copay, coinsurance, and any limitations that apply to mental health treatment. For patients coming in for ongoing therapy or other recurring services, eligibility should also be checked regularly. Insurance information that was correct several months ago may no longer be accurate. Missing Prior Authorization Authorization is another common source of problems for behavioral health providers. Some payers require authorization for certain services or limit the number of visits a patient can receive. If those requirements are missed, the claim can be denied even though the service itself was medically appropriate. The billing team needs to know whether authorization is required and, when it is, keep track of the authorization number, approved visits or units, effective dates, provider, and location. It is also important to know when the approved visits are running out. Finding out after the next claim is denied is too late. Coding Errors Mental health billing depends on accurate coding. The diagnosis and procedure codes need to reflect the service that was actually provided, and the information on the claim should be consistent with the patient’s record. A coding problem can be as simple as missing information or as complicated as a mismatch between the service documented and the code submitted. CMS’s current Medicare guidance for psychiatry and psychology services also emphasizes the connection between documentation and the services reported on the claim. Documentation Problems Documentation is another area that can affect payment. The medical record should support the service that was provided and give enough information to establish medical necessity when required. Depending on the service, that may include the patient’s symptoms, diagnosis, treatment plan, progress, and details of the session. When documentation is incomplete, the billing team may have difficulty supporting the claim if the payer requests records. That is why documentation problems are better addressed before a claim goes out instead of waiting until the payer asks for additional information. Telehealth Billing Errors Telehealth has made behavioral health services more accessible, but it has also added another layer to billing. The practice has to consider the service being provided, the place of service, the payer’s requirements, documentation, and the rules that apply to Medicare telehealth. For 2026, one important Medicare change is that the in-person requirement for certain mental health telehealth services provided to patients at home has been delayed. Under current CMS guidance, the requirement takes effect after December 31, 2027. At that point, an in-person, non-telehealth visit will generally be required within six months before the patient’s first mental health telehealth service. After that, an in-person visit will generally be required within 12 months of each mental health telehealth service, with limited exceptions. CMS also says that patients who started receiving mental health telehealth services at home before January 1, 2028, will be treated as established rather than being subject to the initial six-month in-person visit requirement. They will instead be subject to the ongoing in-person visit requirement after the new rule takes effect. Audio-only services have their own requirements as well. Practices should confirm the current Medicare and payer rules for the particular service rather than assuming the same rules apply to every telehealth claim. How Mental Health Billing Services Help Reduce Denials Denial management should not begin when the denial letter arrives. There are several opportunities to catch billing problems earlier. Verify Eligibility Before the Appointment Checking coverage before the appointment can prevent avoidable surprises later. For patients receiving regular behavioral health care, this is especially important because coverage can change while treatment is still ongoing. A quick eligibility check can reveal changes in coverage, patient responsibility, or behavioral health benefits before the practice provides another service. Check Authorization Before Treatment If a payer requires prior authorization, the information should be checked before the service is provided. The billing team should know how many visits or units were approved, when the authorization expires, and whether it applies to the correct provider and location. This also makes it easier to identify when a new authorization is needed instead of discovering the issue after a claim has been denied. Review Claims Before Submission A pre-submission review can catch many of the smaller issues that create unnecessary denials. Depending on the billing system, this may include checking patient information, coding, required claim fields, and other potential errors. It is much easier to correct a claim

CO-97 Denial Code
Coding

CO-97 Denial Code: What It Means and How to Fix It

/

A CO-97 denial code can be confusing when it first appears on a healthcare claim. The claim may have been submitted correctly, but the payer says the service is already included in the payment for another service or procedure. In simple terms, the payer is saying, “We’re not paying this service separately.” The official Claim Adjustment Reason Code (CARC) 97 means that the benefit for the service is included in the payment or allowance for another service or procedure that has already been adjudicated. CO-97 denials are commonly associated with bundled services, coding combinations, payer-specific payment policies, or services that are considered part of another procedure. The good news is that a CO-97 denial isn’t always the end of the claim. Once you understand why the payer applied it, you can determine whether the service was correctly bundled, whether the claim needs a correction, or whether an appeal is appropriate. What Does CO-97 Mean? CO-97 consists of two parts: CO: Contractual Obligation97: Payment for the service is included in the allowance for another service or procedure. CMS explains that the CO group code assigns financial responsibility to the provider for the unpaid portion of the claim. The “97” portion identifies the reason for the adjustment. For example, suppose a provider bills two services performed during the same encounter. The payer may determine that one service is already included in the reimbursement for the primary procedure. Instead of paying both services separately, the payer bundles them together and applies CO-97 to the additional service. CMS has specifically used CO-97 for services that are bundled into another payable service. CO-97 at a Glance Item  Meaning Denial Code  CO-97  Group Code  CO Reason Code  97 Type  Claim Adjustment Reason Code  Basic Meaning  Service is included in payment for another service or procedure  Common Cause  Bundling or payer payment policy  Provider Responsibility  Usually provider contractual obligation  Next Step  Review claim, coding, payer policy, and related services  Why Do CO-97 Denials Happen? There isn’t just one reason for a CO-97 denial. Bundled Services This is one of the most common causes. Some procedures are designed to be billed together, with payment for the related service included in the primary procedure. CMS uses National Correct Coding Initiative (NCCI) methodologies to identify certain code combinations that should not be separately reported under specific circumstances. CMS also notes that private insurers may choose to adopt NCCI methodologies. Incorrect Modifier Use A modifier may sometimes be necessary to show that two services were separately identifiable. If the appropriate modifier isn’t reported, the payer may consider the services part of the same procedure and apply CO-97. However, a modifier should never be added simply to force payment. The documentation and payer rules need to support separate reporting. Duplicate or Overlapping Services A payer may determine that a service overlaps with another service already processed for the same patient, provider, date, or encounter. The claim may therefore be adjusted because the payer considers the service already included. Payer-Specific Billing Rules Not every payer handles every code combination in exactly the same way. Medicare, Medicaid programs, and commercial insurers may have different reimbursement policies. A claim that is paid separately by one payer may be bundled by another. That’s why the payer’s specific policy should be checked before correcting or appealing a CO-97 denial. Incorrect Code Combination Sometimes the issue is simply that the submitted CPT or HCPCS codes don’t accurately represent the services performed. If the codes create a bundling conflict, the payer may process one service and deny the other with CO-97. How to Fix a CO-97 Denial The first mistake to avoid is immediately resubmitting the same claim. If nothing changes, the same denial may happen again. Instead, follow a structured review. Step 1: Review the ERA or EOB Start with the electronic remittance advice (ERA) or explanation of benefits (EOB). Look at the specific claim line that received CO-97. Check the CPT or HCPCS code, units, modifiers, date of service, and any accompanying Remark Code. CMS explains that remittance advice uses group codes, CARCs, and RARCs to communicate why a claim or claim line was adjusted. The RARC can provide additional information about why the payer applied the adjustment. Step 2: Identify the Other Service CO-97 specifically indicates that the denied service is included in another service or procedure. Find the other code that the payer considered the primary or payable service. Ask: This often reveals the reason behind the denial. Step 3: Check Coding and NCCI Edits Review the applicable coding guidelines and NCCI edits. CMS updates NCCI edit files regularly, with updates generally occurring at least quarterly. If the two codes are subject to a bundling edit, determine whether the services were appropriately reported. Step 4: Review Documentation Documentation matters when deciding whether two services should be reported separately. Review the patient’s medical record, operative report, procedure note, or other relevant documentation. If the documentation does not support separate services, an appeal may not be appropriate. If the record clearly supports separately identifiable services and the payer’s policy allows separate reimbursement, there may be grounds for correction or appeal. Step 5: Check Modifier Requirements If the services were genuinely separate and the payer allows them to be reported separately, determine whether a modifier was required. For example, modifier 59 or an applicable X{EPSU} modifier may be appropriate in certain circumstances. Don’t use a modifier simply because CO-97 appeared. The medical documentation and coding rules need to support its use. Step 6: Correct or Appeal the Claim After reviewing the denial, decide which action makes sense. If the claim was coded incorrectly: Submit a corrected claim according to payer instructions. If the service was properly bundled: Accept the adjustment and don’t rebill it as a separate service. If the service was separately reportable and documentation supports it: Submit an appeal with the necessary documentation and explanation. Can You Appeal a CO-97 Denial? Yes, a CO-97 denial can sometimes be appealed, but not every CO-97 denial should

Revenue cycle management services
Revenue Cycle

Revenue Cycle Management Services USA

/

Getting paid for healthcare services is rarely as simple as sending a claim and waiting for a payment. A patient may have inactive insurance. A procedure may require prior authorization. A claim may be rejected because of a coding issue. A payer may request additional documentation. Even after a claim is approved, the payment still has to be posted and reconciled. Each of these steps can affect a healthcare practice’s revenue. That is why many providers in the USA turn to revenue cycle management services. Instead of treating billing, claims, denials, and accounts receivable as separate tasks, RCM brings them together into one connected process. The goal is straightforward: help practices capture the revenue they have earned, reduce avoidable delays, and understand exactly what is happening with their financial performance. For practices considering RCM outsourcing, the real question isn’t simply which company can submit claims. It’s which partner can manage the entire revenue cycle, provide measurable results, work with existing technology, and give the practice visibility into its numbers. What Are Revenue Cycle Management Services? Revenue cycle management services cover the financial process that begins when a patient schedules an appointment and continues until the healthcare provider receives payment. A complete RCM workflow can include: The important part is how these functions work together. For example, if a patient’s insurance eligibility isn’t verified correctly, the problem can eventually appear as a denied claim. If the claim is denied and nobody follows up, it becomes an aging A/R balance. If that balance remains unresolved for too long, the practice may eventually have to write off money it could have collected. A good RCM process tries to catch the problem earlier. Medical Billing and RCM Are Not the Same Thing These terms are often used together, but there is a difference. Medical billing generally focuses on preparing and submitting claims, posting payments, following up on unpaid claims, and handling denials. Revenue cycle management covers a much wider portion of the financial process. RCM can begin with patient registration and insurance verification, continue through authorization, coding and claim submission, and then move into payment posting, denial management, A/R, patient collections, and reporting. Think of medical billing as one part of the revenue cycle. RCM looks at the whole journey. For a practice with a simple billing workflow, traditional medical billing may be enough. But if the practice is dealing with high denial rates, authorization problems, aging A/R, inconsistent collections, or limited financial visibility, a broader RCM approach may be more useful. Why Revenue Cycle Management Matters for US Healthcare Providers A practice can have a full schedule and still have a cash flow problem. The reason is simple. Patient volume doesn’t automatically translate into collected revenue. Consider a practice that submits 1,000 claims. If even a portion of those claims are rejected, denied, underpaid, or left without follow-up, a significant amount of money can remain tied up in the revenue cycle. That’s why RCM teams track specific performance indicators rather than looking only at total monthly collections. Common metrics include: HFMA’s revenue cycle guidance recommends measuring initial denial rates by both claim volume and dollars, along with metrics such as time from denial to appeal and time from denial to resolution. A 2026 HFMA AI implementation guide provides an example benchmark framework using 30 to 32 days in A/R, a 95% clean claim rate, a 5% to 6% denial rate, and 2.5% to 4.5% cost to collect. These are benchmark examples, not guarantees for every practice, and actual performance varies by specialty and payer mix. That distinction matters. A cardiology group and a primary care clinic shouldn’t necessarily be judged against exactly the same numbers. What matters most is establishing a baseline and measuring improvement. The RCM Process From Patient Visit to Payment Getting the basics right at registration saves a lot of headaches down the road. This is where you confirm the patient’s info is correct, check their insurance is actually active, and figure out what they’ll owe out of pocket. Catching a coverage problem here before the visit even happens is a lot easier than fighting a denied claim after the fact. Patient Registration and Insurance Verification The revenue cycle starts before the claim is created. Accurate patient demographics and insurance information are essential. The RCM team may verify whether coverage is active, confirm benefits, check the patient’s responsibility, and identify potential coverage problems. Catching an insurance issue before the appointment is much easier than trying to resolve it after the claim has been denied. Prior Authorization and Referrals Some procedures, medications, imaging services, and treatments require prior authorization. An RCM team can help identify authorization requirements, submit documentation, monitor requests, and keep authorization information connected to the patient’s account. This is especially important for specialties where procedures and advanced diagnostic services frequently require payer approval. Coding and Charge Capture Once care is provided, the services need to be accurately documented and coded. Depending on the service, this can involve ICD-10-CM, CPT, HCPCS, modifiers, and payer-specific billing requirements. A missing charge or incorrect code can affect reimbursement. It can also create unnecessary denials and additional work later. That’s why coding shouldn’t be treated as a quick step before submitting the claim. Claim Scrubbing and Electronic Submission Before a claim is sent to the payer, claim-scrubbing technology can check for common errors. Depending on the system, it may flag: Claims can then be transmitted electronically through a clearinghouse using EDI transactions. The objective is to catch preventable problems before they become payer rejections or denials. Payment Posting and ERA Once a payer processes a claim, the payment and remittance information need to be recorded accurately. Electronic remittance advice, or ERA, can automate part of this process. The RCM team should also compare expected reimbursement with actual payment. If a payer pays less than the contracted amount, that may require further investigation. This is where payment posting becomes more than data entry. Accurate reconciliation helps identify revenue that may otherwise go unnoticed.

Scroll to Top

Get a Quote

Get a Quote

Fill the following form to join the event

Established Practice

Startup Practice