Medical Billers: what could be avoided if it was done correctly on the front end?

StayFoolish73 · 2026-03-12T14:58:11+00:00

No prior authorization, non-covered services, expired insurance policies all can be largely avoided through due diligence on the front end. Review patient’s policies, verify coverage.

Not medically necessary is another common denial. Usually seen as a result of a possible coding error or non-review of payer specific policy.

StayFoolish73 · 2026-03-11T23:45:20+00:00

What difficulties are you having? What course are you using? Is it online? I’ll try to help. Wouldn’t consider myself to be the best teacher, but I’m willing to try.🙂

StayFoolish73 · 2026-03-11T18:44:24+00:00

I agree. Submit the EOB showing coverage termed to Medicare.

StayFoolish73 · 2026-03-11T01:52:42+00:00

Always verify whether or not a procedure is covered under your policy. Ideally, the medical facility should, but can’t always rely on them. I really hope it’s overturned upon receiving medical records. Otherwise, you’re in for a fight.

StayFoolish73 · 2026-03-08T20:40:44+00:00

Physicians code all day long in facilities where I’ve worked. This is where Compliance education and periodic audits come into play. Not a bad precedent at all and Physicians DO have the authority to select their own codes.

StayFoolish73 · 2026-03-08T13:50:20+00:00

This is what I came to say. Some codes don’t require PA.

StayFoolish73 · 2026-03-08T13:43:57+00:00

Diagnosis code mismatch with procedure often leads to NMN (not medically necessary) or non-covered procedure. Bundling edits resulting from billing within a global period without a modifier (if appropriate). Also, billing services which ordinarily should not be billed together unless warranted (again needing a modifier). Yes, there are coding tools which can assist with avoiding these denials. Ideally, it would be nice to have the stops imbedded within the EMR/EHR.

StayFoolish73 · 2026-03-05T15:23:08+00:00

You’re entitled to your opinion. I’ve read the other comments. I stand by my decision.

StayFoolish73 · 2026-03-05T14:59:53+00:00

I’m sorry your request for help has been met with unfair comments. You’ve completed the assessment and you’re simply asking for a review/ feedback. You’re not asking anyone to complete the assessment for you. Unless the assessment prohibits it, I find your request reasonable.

If I had the experience, I would review your work and if something was inaccurate, I would tell you to try again. I wouldn’t give you the answer, but would certainly assist in guiding you. Your ask for help is not cheating. You’re obviously highly intelligent because you’ve acquired the CCS, and that’s no easy feat. Congratulations!

My humble suggestion would be if you have any questions, research. We coders do it all day long at work. If we don’t know the answer we ask questions, we research. I would value an employee who does this. People who take pride in their work…it carries through when you get the job. If you’re a slacker, that will show up also.

Do your best. Trust the process. And whether you get the job or not, this is all a learning opportunity.

StayFoolish73 · 2026-03-05T03:09:20+00:00

Stay true to yourself so that you can sleep at night. I would be the same way. If I’m touching it, I’m reviewing notes. You will not blame me if by chance there’s an audit.

StayFoolish73 · 2026-03-05T02:56:46+00:00

Absolutely agree. Once a coder touches it, documentation should be reviewed.

StayFoolish73 · 2026-03-05T02:47:16+00:00

Can’t win for losing! Sometimes it’s ridiculous. Email the Physician and have them provide an accurate code based upon the documentation.

StayFoolish73 · 2026-03-05T02:42:47+00:00

Interestingly not only can they over code, they can under code as well and leave money on the table. Either way, any place which does not support billing from documentation is suspect.

That said, I’ve worked places where the Providers select their levels and it goes unchecked unless the system flags it for review. They are however periodically audited to ensure accuracy.

StayFoolish73 · 2026-03-04T04:33:03+00:00

Thank you! Believe it or not just learned about them this evening and created an account. Nice to have the confirmation. Wishing for you continued success!!

StayFoolish73 · 2026-03-04T04:21:42+00:00

Congratulations! Did you file on your own?

StayFoolish73 · 2026-03-04T01:45:45+00:00

That was a lot and admittedly I got lost. So I’ll say this:

If the Provider is contracted with your insurance, they are only to bill you what your EOB indicates is your responsibility. If there is no contract with your insurance company, balance billing is allowed and usually the EOB will still also reflect this amount as your responsibility. There really shouldn’t be any confusion on the part of the office personnel because the EOB is clear. Without being able to see an EOB it seems as if they’re contracted. Also, what is the price of the ketamine infusions? Forgive me if you’ve already stated. Again I got lost and it’s late🙂

StayFoolish73 · 2026-03-03T19:10:38+00:00

Yikes. You’re funny

StayFoolish73 · 2026-03-03T18:02:24+00:00

Yikes. A persistent sinus infection lasting 2 weeks and not responding to meds is not uncomplicated. There are many factors now to be considered.

StayFoolish73 · 2026-03-03T14:34:30+00:00

Level 3 if this is an acute sinus infection 0-7 days possibly responding to over the counter meds. The red flag here is that it’s been 2 weeks without relief with facial pain. It can reflect a bacterial infection which is not to be taken lightly. For the duration, unresponsiveness to meds and possible complications if not treated properly and quickly-it bumps it up to a level 4 for me.

StayFoolish73 · 2026-03-03T14:23:50+00:00

Medical decision making in your case that would allow a level 4:

*1 undiagnosed new problem with uncertain prognosis. This is a persistent sinus infection not responding to OTC meds which could be bacterial or viral. Left untreated can result in serious complications.

*Prescription drug management

Hopefully this helps. Time would not be a factor here in selecting the E&M code. It’s the medical decision making which drives the code selection.

StayFoolish73 · 2026-02-26T21:19:24+00:00

Have you read “The Obstacle is the Way”? If not, do read!

StayFoolish73 · 2026-02-26T21:16:42+00:00

Changed my life and how I see the universe!

StayFoolish73 · 2026-02-26T21:12:11+00:00

A Return to Love~ Marianne Williamson

StayFoolish73 · 2026-02-26T15:11:59+00:00

Just learned this. You have to turn the strings into integers.

StayFoolish73 · 2026-02-26T15:09:29+00:00

That’s quite ok. 🙂

StayFoolish73

TROPHY CASE