The success of your practice relies heavily on the accuracy of your medical billing. It’s essential to ensure precise processing of claims, using the correct cardiology CPT codes and modifiers. The accuracy of your coding directly influences your potential reimbursement, underscoring the importance of meticulous coding to optimize collections.

Cardiology CPT Code Ranges in 2024

The following are the CPT codes for cardiology services used in 2024:

• 0051T – Implantation of an artificial heart system with recipient cardiectomy
• 0052T – Replacement or repair of components of artificial heart system (thoracic unit)
• 0053T – Replacement or repair of components of artificial heart system (excluding thoracic unit)
• 33496 – Repair of non-structural prosthetic valve dysfunction with cardiopulmonary bypass as a separate procedure.
• 33542 – Myocardial resection, such as ventricular aneurysmectomy.
• 33545 – Repair of postinfarction ventricular septal defect, with or without myocardial resection.
• 33548 – Surgical ventricular restoration procedure, which includes prosthetic patch placement when performed.
• 33732 – Correction of cor triatriatum or supravalvular mitral ring through resection of the left atrial membrane.

Thoracic Procedures

• 32658 – Surgical thoracoscopy with pericardial clot or foreign body removal
• 32659 – Surgical thoracoscopy with pericardial window creation or partial sac resection for drainage
• 32661 – Surgical thoracoscopy with pericardial cyst, tumor, or mass excision

Pericardial Procedures

• 33020 – Pericardiotomy for clot or foreign body removal (primary procedure)
• 33025 – Creation of pericardial window or partial resection for drainage
• 33030 – Subtotal or complete pericardiectomy without cardiopulmonary bypass
• 33031 – Subtotal or complete pericardiectomy with cardiopulmonary bypass
• 33050 – Removal of pericardial cyst or tumor

Cardiac Tumor Excision and Ablation

• 33120 – Excision of intracardiac tumor with resection using cardiopulmonary bypass
• 33130 – Removal of external cardiac tumor

Cardiac Arrhythmia Ablation

• 33250 – Surgical ablation of supraventricular arrhythmogenic focus or pathway without cardiopulmonary bypass
• 33251 – Surgical ablation of supraventricular arrhythmogenic focus or pathway with cardiopulmonary bypass
• 33254 – Surgical tissue ablation and reconstruction of atria (limited)
• 33255 – Surgical tissue ablation and reconstruction of atria (extensive) without cardiopulmonary bypass
• 33256 – Surgical tissue ablation and reconstruction of atria (extensive) with cardiopulmonary bypass
• 33257 – Surgical tissue ablation and reconstruction of atria (limited) performed concurrently with other cardiac procedures
• 33258 – Surgical tissue ablation and reconstruction of atria (extensive) performed concurrently with other cardiac procedures without cardiopulmonary bypass
• 33259 – Surgical tissue ablation and reconstruction of atria (extensive) performed concurrently with other cardiac procedures with cardiopulmonary bypass
• 33261 – Surgical ablation of ventricular arrhythmogenic focus with cardiopulmonary bypass
• 33265 – Surgical endoscopic tissue ablation and reconstruction of atria (limited) without cardiopulmonary bypass
• 33266 – Surgical endoscopic tissue ablation and reconstruction of atria (extensive) without cardiopulmonary bypass
• 33267 – Open exclusion of left atrial appendage using any method
• 33268 – Open exclusion of left atrial appendage performed concurrently with other sternotomy or thoracotomy procedures using any method
• 33269 – Thoracoscopic exclusion of left atrial appendage using any method

Cardiotomy and Cardiac Wound Repair

• 33300 – Repair of cardiac wound without bypass
• 33305 – Repair of cardiac wound with cardiopulmonary bypass
• 33310 – Exploratory cardiotomy (includes removal of foreign bodies, atrial, or ventricular thrombus) without bypass
• 33315 – Exploratory cardiotomy (includes removal of foreign bodies, atrial, or ventricular thrombus) with cardiopulmonary bypass

Transcatheter Aortic Valve Replacement (TAVR/TAVI)

• 33365 – Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve via transaortic approach
• 33366 – Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve via transapical exposure

Aortic Valve Procedures

• 33390 – Open valvuloplasty of the aortic valve with cardiopulmonary bypass; simple procedure
• 33391 – Open valvuloplasty of the aortic valve with cardiopulmonary bypass; complex procedure
• 33404 – Construction of apical-aortic conduit
• 33405 – Open replacement of aortic valve with prosthetic valve other than homograft or stentless valve using cardiopulmonary bypass
• 33406 – Open replacement of aortic valve with allograft valve (freehand) using cardiopulmonary bypass
• 33410 – Open replacement of aortic valve with stentless tissue valve using cardiopulmonary bypass
• 33411 – Replacement of aortic valve with aortic annulus enlargement, noncoronary sinus
• 33412 – Replacement of aortic valve with transventricular aortic annulus enlargement (Konno procedure)
• 33413 – Replacement of aortic valve by translocation of autologous pulmonary valve with allograft replacement of pulmonary valve (Ross procedure)
• 33414 – Repair of left ventricular outflow tract obstruction by patch enlargement
• 33415 – Resection or incision of subvalvular tissue for discrete subvalvular aortic stenosis
• 33416 – Ventriculomyotomy (-myectomy) for idiopathic hypertrophic subaortic stenosis
• 33417 – Aortoplasty (gusset) for supravalvular stenosis
• 33440 – Aortic valve replacement through the translocation of an autologous pulmonary valve and enlargement of the left ventricular outflow tract.

Mitral Valve Procedures

• 33420 – Mitral valve valvotomy performed on a closed heart.
• 33422 – Mitral valve valvotomy performed on an open heart with cardiopulmonary bypass.
• 33425 – Mitral valve valvuloplasty conducted with cardiopulmonary bypass.
• 33426 – Mitral valve valvuloplasty conducted with cardiopulmonary bypass, including the placement of a prosthetic ring.
• 33427 – Mitral valve valvuloplasty conducted with cardiopulmonary bypass, involving radical reconstruction with or without a ring.
• 33430 – Replacement of the mitral valve with the assistance of cardiopulmonary bypass.

Tricuspid Valve Procedures

• 33460 – Tricuspid valve valvectomy performed with cardiopulmonary bypass.
• 33463 – Tricuspid valve valvuloplasty performed without ring insertion.
• 33464 – Tricuspid valve valvuloplasty performed with ring insertion.
• 33465 – Replacement of the tricuspid valve with the assistance of cardiopulmonary bypass.
• 33468 – Repositioning and plication of the tricuspid valve for Ebstein anomaly.

Pulmonary Valve Procedures

• 33471 – Pulmonary valve valvotomy conducted on a closed heart via the pulmonary artery.
• 33474 – Pulmonary valve valvotomy conducted on an open heart with cardiopulmonary bypass.
• 33475 – Replacement of the pulmonary valve.
• 33476 – Resection of the right ventricle for infundibular stenosis, with or without commissurotomy.
• 33478 – Augmentation of the outflow tract, with or without commissurotomy or infundibular resection.

Ventricular Septal Defect (VSD) Repair

• 33600 – Closure of the atrioventricular valve (mitral or tricuspid) by suture or patch.
• 33602 – Closure of the semilunar valve (aortic or pulmonary) by suture or patch.
• 33608 – Repair of complex cardiac anomaly other than pulmonary atresia with ventricular septal defect by construction or replacement of a conduit.
• 33610 – Surgical enlargement of the ventricular septal defect for repair of complex cardiac anomalies (e.g., single ventricle with subaortic obstruction).
• 33611 – Repair of double outlet right ventricle with intraventricular tunnel repair.
• 33612 – Repair of double outlet right ventricle with intraventricular tunnel repair, including repair of right ventricular outflow tract obstruction.
• 33615 – Closure of atrial septal defect and anastomosis of atria or vena cava to pulmonary artery for repair of complex cardiac anomalies (e.g., tricuspid atresia).
• 33617 – Repair of complex cardiac anomalies (e.g., single ventricle) by modified Fontan procedure.
• 33619 – Repair of single ventricle with aortic outflow obstruction and aortic arch hypoplasia (hypoplastic left heart syndrome) (e.g., Norwood procedure).
• 33641 – Repair of the atrial septal defect, secundum, with or without patch using cardiopulmonary bypass.
• 33645 – Direct or patch closure of sinus venosus, with or without anomalous pulmonary venous drainage.
• 33647 – Repair of atrial septal defect and ventricular septal defect, with direct or patch closure.
• 33660 – Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect), with or without atrioventricular valve repair.
• 33665 – Repair of intermediate or transitional atrioventricular canal, with or without atrioventricular valve repair.
• 33670 – Repair of the complete atrioventricular canal, with or without prosthetic valve.
• 33675 – Closure of multiple ventricular septal defects.
• 33676 – Closure of multiple ventricular septal defects, with pulmonary valvotomy or infundibular resection (acyanotic).
• 33677 – Closure of multiple ventricular septal defects, with removal of pulmonary artery band, with or without gusset.
• 33681 – Closure of single ventricular septal defect, with or without patch.
• 33684 – Closure of single ventricular septal defect, with or without a patch, including pulmonary valvotomy or infundibular resection (acyanotic).
• 33688 – Closure of single ventricular septal defect, with or without patch, including removal of pulmonary artery band, with or without gusset.
• 33692 – Complete repair of tetralogy of Fallot without pulmonary atresia.
• 33694 – Comprehensive repair of tetralogy of Fallot without pulmonary atresia, including the use of a transannular patch.
• 33697 – Comprehensive repair of tetralogy of Fallot with pulmonary atresia, involving the creation of a conduit from the right ventricle to the pulmonary artery and closure of the ventricular septal defect.

Sinus of Valsalva Procedures

• 33702 – Surgical correction of sinus of Valsalva fistula with the assistance of cardiopulmonary bypass.
• 33710 – Surgical correction of sinus of Valsalva fistula with cardiopulmonary bypass, combined with repair of a ventricular septal defect.
• 33720 – Surgical repair of sinus of Valsalva aneurysm with the aid of cardiopulmonary bypass.

Atrial Septostomy and Atrial Baffle Procedures

• 33735 – Atrial septectomy or septostomy performed on a closed heart, known as the Blalock-Hanlon type operation.
• 33736 – Atrial septectomy or septostomy conducted on an open heart with the support of cardiopulmonary bypass.
• 33737 – Atrial septectomy or septostomy conducted on an open heart with the occlusion of inflow.

Transposition of Great Arteries Repair

• 33770 – Repair of transposition of the great arteries with ventricular septal defect and subpulmonary stenosis without surgically enlarging the ventricular septal defect.
• 33774 – Correction of transposition of the great arteries through the atrial baffle procedure (e.g., Mustard or Senning type) with cardiopulmonary bypass.
• 33776 – Correction of transposition of the great arteries through the atrial baffle procedure (e.g., Mustard or Senning type) with cardiopulmonary bypass, along with closure of the ventricular septal defect.
• 33780 – Correction of transposition of the great arteries through aortic pulmonary artery reconstruction (e.g., Jatene type) with the closure of the ventricular septal defect.
• 33782 – Aortic root translocation with the repair of the ventricular septal defect and pulmonary stenosis (i.e., Nikaidoh procedure) without reimplantation of coronary ostia.
• 33783 – Aortic root translocation with the repair of the ventricular septal defect and pulmonary stenosis (i.e., Nikaidoh procedure) with reimplantation of one or both coronary ostia.
• 33786 – Total repair of truncus arteriosus, following the Rastelli type operation.

Aortopulmonary Septal Defect Repair

• 33813 – Obliteration of aortopulmonary septal defect without the use of cardiopulmonary bypass.
• 33814 – Obliteration of aortopulmonary septal defect with the aid of cardiopulmonary bypass.

Ventricular Assist Device Insertion and Removal

• 33920 – Repair of pulmonary atresia with ventricular septal defect by constructing or replacing a conduit from the right or left ventricle to the pulmonary artery.
• 33975 – Insertion of an extracorporeal ventricular assist device for a single ventricle.
• 33976 – Insertion of an extracorporeal ventricular assist device for biventricular support.
• 33977 – Removal of an extracorporeal ventricular assist device for a single ventricle.
• 33978 – Removal of an extracorporeal ventricular assist device for biventricular support.
• 33979 – Insertion of an implantable intracorporeal ventricular assist device for a single ventricle.
• 33980 – Removal of an implantable intracorporeal ventricular assist device for a single ventricle.

Cardiology Modifiers

Add modifiers where you can to improve the accuracy of billing and reduce the risk of the claim getting denied. The following are recent additions to the list of modifiers:

• 310 – Not vaccinated against COVID-19
• 311 – Partly vaccinated against COVID-19
• 39 – Indicates any other under-immunized status

Ensuring the accuracy of your medical practice billing and accuracy is important. If your urology practice’s codes are not accurate, then claims may be delayed or even denied. So, the more accurate your codes, the more collections you can receive.

Urology CPT Code Ranges in 2024

Below are the urology CPT codes for 2024.

Cystectomy CPT Codes

These CPT codes pertain to cystectomies:

• 51550 – Partial cystectomy; simple
• 51555 – Partial cystectomy; complicated (i.e., in a difficult location or previously had surgery)
• 51565 – Partial cystectomy; with ureteroneocystostomy (repositioning of ureter(s) into the bladder)
• 51570 – Complete cystectomy
• 51575 – Complete cystectomy; accompanied by bilateral pelvic lymphadenectomy, encompassing obturator nodes, hypogastric, and external iliac
• 51580 – Complete cystectomy, including ureterosigmoidostomy or ureterocutaneous transplant
• 51585 – Complete cystectomy, including ureterosigmoidostomy or ureterocutaneous transplantation, along with bilateral pelvic lymphadenectomy involving obturator nodes, hypogastric, and external iliac
• 51590 – Complete cystectomy with intestinal connection, involving either ureteroileal conduit or sigmoid bladder
• 51595 – Complete cystectomy, along with either a ureteroileal conduit or sigmoid bladder, incorporating intestinal connection; alongside the removal of lymph nodes in both pelvic regions, covering external iliac, hypogastric, and obturator nodes
• 51596 – Complete cystectomy, with continent diversion, employing an open technique, utilizing any portion of the small and/or large intestine to form a neobladder

Nephrectomy CPT Codes

These CPT codes relate to nephrectomies:

• 50220 – Nephrectomy, involving partial removal of the ureter, utilizing any open approach, including rib resection
• 50225 – Nephrectomy, involving partial ureterectomy, utilizing any open approach, including rib resection; complicated due to prior surgery on the same kidney
• 50230 – Nephrectomy, involving partial ureterectomy, utilizing any open approach, including rib resection; performed radically, with regional lymphadenectomy and/or vena caval thrombectomy
• 50334 – Nephrectomy, with complete ureterectomy and bladder cuff; through the same incision
• 50236 – Nephrectomy, with total ureterectomy and bladder cuff; through a separate incision
• 50240 – Partial nephrectomy
• 50543 – Partial laparoscopic nephrectomy
• 50545 – Laparoscopy with radical nephrectomy (comprising removal of Gerota’s fascia and surrounding adipose tissue, excision of regional lymph nodes, and renalectomy)
• 50546 – Laparoscopic nephrectomy, involving partial ureterectomy
• 50548 – Laparoscopic nephrectomy with total ureterectomy

Prostatectomy CPT Codes

These CPT codes are for prostatectomies:

• 55801 – Perineal subtotal prostatectomy, encompassing management of postoperative hemorrhage, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy
• 55810 – Radical perineal prostatectomy
• 55812 – Radical perineal prostatectomy, accompanied by lymph node biopsy(s) (limited pelvic lymphadenectomy)
• 55815 – Perineal radical prostatectomy, with bilateral pelvic lymphadenectomy involving external iliac, hypogastric, and obturator nodes
• 55821 – Suprapubic subtotal prostatectomy, conducted in 1 or 2 stages, including management of postoperative hemorrhage, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy
• 55831– Retropubic subtotal prostatectomy, involving control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy
• 55840 – Retropubic radical prostatectomy, with or without preservation of nerves
• 55842 – Retropubic radical prostatectomy, with or without preservation of nerves, accompanied by lymph node biopsy(s) (limited pelvic lymphadenectomy)
• 55845 – Retropubic radical prostatectomy, with or without preservation of nerves, with bilateral pelvic lymphadenectomy encompassing external iliac, hypogastric, and obturator nodes
• 55866 – Surgical laparoscopic radical retropubic prostatectomy, inclusive of nerve sparing, with robotic assistance, if performed
• 55867 – Surgical laparoscopic simple subtotal prostatectomy, involving the control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy, with robotic assistance, if performed

New 2024 CPT Codes

These are new CPT codes:

• 52284 – Cystourethroscopy; with mechanical urethral dilation and drug delivery for urethral stricture, utilizing a specialized drug-coated balloon catheter. Replaces Category III code 0499T
• 64596 – The initial insertion or replacement of a percutaneous electrode array with an integrated neurostimulator for peripheral nerve stimulation, including imaging guidance
• +64597 – An add-on code to report each additional electrode array insertion or replacement
• 64598 – Revising or removing a neurostimulator electrode array with an integrated neurostimulator for peripheral nerve stimulation
• 99459 – Separately listing a female pelvic exam in addition to the primary procedure code during preventive medicine or E/M services

Revised 2024 CPT Codes

These are the revised CPT codes:

• 63685 – Placement or substitution of spinal neurostimulator pulse generator or receiver, utilizing direct or inductive coupling
• 63688 – Modification or extraction of implanted spinal neurostimulator pulse generator or receiver
• 64590 – Inserting or replacing a peripheral, sacral, or gastric neurostimulator pulse generator or receiver, including pocket creation and connection between electrode array and pulse generator or receiver
• 64595 – Revising or removing a peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with a detachable connection to the electrode array
• 0587T – Percutaneous implantation or replacement of integrated single device neurostimulation system, comprising electrode array and receiver or pulse generator, with analysis, programming, and imaging guidance as necessary, targeting the posterior tibial nerve
• 0588T – Revision or removal of integrated single-device neurostimulation system, including electrode array and receiver or pulse generator, with analysis, programming, and imaging guidance as required, focusing on the posterior tibial nerve
• 0589T – Electronic analysis with basic programming of implanted integrated neurostimulation system (e.g., electrode array and receiver), involving contact group(s), amplitude, pulse width, frequency (Hz), on/off cycling, burst, dose lockout, patient-selectable parameters, responsive neurostimulation, detection algorithms, closed-loop parameters, and passive parameters, conducted by a physician or other qualified healthcare professional, targeting the posterior tibial nerve, with 1-3 parameters

Urology Modifiers

In medical billing, using modifiers alongside the original CPT code improves accuracy. The more accurate a claim is, the less likely it is for a claim to face denials. Below are the recent additions to the list of modifiers for urology departments:

• -24 – Unrelated E/M service by the same physician/other qualified health care professional during a postoperative period
• -25 – separately identifiable E/M service by the same physician
• 95 – telehealth service
• 93 – synchronous telehealth service
• JW – drug discarded, not administered to any patient
• JZ – no amount of drug is discarded
• 310 – not vaccinated against COVID-19
• 311 – partly vaccinated against COVID-19
• 39 – indicates any other under-immunized status

Make the most of your hospitalist billing practice by keeping CPT codes and modifiers accurate. When recorded and reported accurately, this can save healthcare providers time and money by reducing patient billing errors. Check the 2024 hospitalist billing codes to maximize patient claim profits.

Hospitalist Code Ranges for 2024

Here are the updated CPT codes for hospitalists in 2024:

• 99221: Hospital inpatient care services (new or established patient)
• 99222: Hospital inpatient care services (new or established patient)
• 99223: Hospital inpatient care services (new or established patient)
• 99231: Subsequent hospital care services
• 99232: Subsequent hospital care services
• 99233: Subsequent hospital care services
• 99238: Hospital discharge services
• 99239: Hospital discharge services
• 99252: Outpatient consultation services (new or established patient)
• 99253: Outpatient consultation services (new or established patient)
• 99254: Outpatient consultation services (new or established patient)
• 99255: Outpatient consultation services (new or established patient)
• 99291: Critical care services
• 99292: Critical care services
• 99242: Inpatient consultation services (new or established patient)
• 99243: Inpatient consultation services (new or established patient)
• 99244: Inpatient consultation services (new or established patient)
• 99245: Inpatient consultation services (new or established patient)

Hospitalist Modifiers

Increase CPT code accuracy with correct modifiers. These are the 2024 hospitalist modifiers:

• 25: Indicates a visit is separate from a procedure performed on the same day
• 310: Not vaccinated against COVID-19
• 311: Partly vaccinated against COVID-19
• 39: Indicates any other under-immunized status

To add more detail to billing reports, dermatology offices can benefit from using up-to-date CPT codes and modifiers. These reports can increase billing accuracy and prevent any missed billing opportunities for medical services. Your dermatology practice should stay informed of the 2024 CPT codes and modifiers.

Common Dermatology CPT Codes 2024

These are the most common dermatology procedures codes for 2024.

Evaluation and Management

Consultations

The following are the 2024 consultation codes:

• 99242: Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and straightforward medical decision-making
• 99243: Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and a low level of medical decision-making
• 99244: Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making
• 99245: Office or other outpatient consultation for a new or established patient, which requires a medically appropriate history and/or examination and a high level of medical decision-making

Visits and Evaluations

• 99201: Problem-focused office visit from new patient
• 99202: Expanded problem-focused office visit from new patient
• 99203: Detailed office visit from new patient
• 99204: Comprehensive office visit from new patient with review of 2-9 symptoms
• 99205: Comprehensive office visit from a new patient with a review of 10 or more symptoms
• 99211: Straightforward office visit from established patient
• 99212: Problem-focused office visit from established patient
• 99213: Expanded problem-focused office visit from established patient
• 99214: Detailed office visit from established patient
• 99215: Comprehensive office visit from established patient

Biopsies

• 11100: Biopsy of skin, subcutaneous tissue and mucous membrane (including simple closure), unless otherwise listed; single lesion
• 11101: Biopsy of skin, subcutaneous tissue and mucous membrane (including simple closure), unless otherwise listed; each additional lesion
• 11102: Tangential biopsy of skin; single lesion
• 11103: Tangential biopsy of skin; each separate/additional lesion
• 11104: Punch biopsy of skin; single lesion
• 11105: Punch biopsy of skin; each separate/additional lesion
• 11106: Incisional biopsy of skin; single lesion
• 11107: Incisional biopsy of skin; each separate/additional lesion

Destruction of Lesions

• 17000: Destruction of premalignant lesions; first lesion
• 17003: Destruction of premalignant lesions; 2-14 lesions
• 17110: Destruction of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions

Mohs Surgery

• 17311: Mohs micrographic technique on head, neck, hands, feet; first stage
• 17312: Mohs micrographic technique on head, neck, hands, feet; each additional stage
• 17313: Mohs micrographic technique on trunk, arms, and legs; first stage
• 17314: Mohs micrographic technique on trunk, arms, and legs; each additional stage

Excisions

• 11403: Excision, benign lesion including margins; trunk, arms, or legs
• 11603: Excision, malignant lesion including margins; trunk, arms or legs

Phototherapy

• 96900: Actinotherapy (ultraviolet light)
• 96910: Photochemotherapy; tar and ultraviolet B or petrolatum and ultraviolet B
• 96567: Photodynamic therapy by external application of light to destroy premalignant and malignant lesions
• J7308: Aminolevulinic acid HCL for topical administration

Laser Treatment

• 96920: Laser treatment for inflammatory skin disease
• 96921: Laser treatment for inflammatory skin disease

2024 Modifiers

Modifiers exist to distinguish any repeat codes. These are the 2024 modifiers for dermatology:

• 25: Separate evaluation on the same day as another procedure or service
• 59: Repetition of procedure on a different extremity
• 91: Repeat tests taken on the same day with different specimens at different times
• 95: synchronous telemedicine service rendered via real-time Interactive audio and video telecommunications system
• 310: Not vaccinated against COVID-19
• 311: Partly vaccinated against COVID-19
• 39: Indicates any other under-immunized status

What Is a Claim Denial?

A claim denial is a term used when a health insurance company refuses to pay for any medical treatment that was provided. While it can be incredibly frustrating for a patient to get denied healthcare coverage, there may be some valid reasons an insurance company could not accept payment reimbursement. In some cases, a claim denial could change if you figure out the mistake or missing piece of information needed to refile a claim.

What Are the Common Reasons a Claim May Be Denied?

The carrier or insurance company may be unable to cover a form of medical care for many reasons, such as a patient not receiving a professional medical order from a certified provider, or perhaps the medical treatment simply isn’t included in the health insurance plan a patient signed up for. Here are the seven most common reasons a claim may be denied:

• Coding mistakes
• Lack of pre-approved authorization
• Treatment not a medical necessity
• Billing claim was filed late
• Claim was expired or lost
• The care you need isn’t covered in your plan
• The provider you used was out of network

#1

Coding Mistakes

Sometimes claims denials could simply come down to incorrect coding. This is why having a system in place to accurately report medical billing is essential, as it can minimize claim denials and unnecessary costs for patients. If this is the reason your claim is denied, it could easily be corrected by resubmitting the claim with the correct codes. You should be careful not to allow coding mistakes to become a habit because it might trigger a fraud audit.

#2

No Pre-Approved Authorization

If you require hospitalization, surgery, medications, or other care for a health condition, you will need a certified medical professional to approve the treatment plan. If a patient seeks treatment on their own without medical approval, most insurance companies will not accept the charges.

#3

Criteria for Medical Necessity Weren’t Met

Sometimes a doctor may approve treatment, but then the insurance company will disagree with the approval and deem certain treatments unnecessary for some patients. Usually, these companies have a certain list of criteria that need to be met before an operation or treatment can be deemed medically necessary.

#4

Late Claim Filing

In some instances, timing may be the biggest factor for a claim being denied. Insurance companies will not pay for medical bills that were claimed too long after the treatment was provided. Typically, the window of time provided is 30 to 90 days.

#5

Lost or Expired Claim

Sometimes it isn’t a patient or medical provider’s fault for a claim being denied. Mistakes happen, and the insurance company may have simply lost a claim and only rediscovered it when it was too late. If this happens, a new claim will need to be made from a medical provider to ensure accurate payment.

#6

Insurance Plan Doesn’t Cover the Procedure

Some kinds of medical care may not be covered in an insurance plan. Patients and providers should always confirm with insurance providers that the care needed is covered before undergoing any major medical interventions to avoid out-of-pocket expenses.

#7

Out-Of-Network Healthcare Provider

If a patient uses a medical service or facility not included in their insurance plan, a claim could be denied due to it being out-of-network care. Patients should always confirm before receiving care if their provider is listed in the insurance company’s network.

What Should You Do if a Patient’s Claim Is Denied?

If your practice keeps having patients’ claims denied, you may require a more robust medical billing system to keep a set of checks and balances organized. This could include minimizing coding errors, ensuring timely billing, and adhering to compliance processes to ensure your patients aren’t overbilled and that your medical practice gets reimbursed correctly for the services provided.

What Is Medical Billing?

Medical billing is a widely-used term for the simple process of submitting billing claims to a patient after they have received medical care, and then following up on those claims to insurance companies until they have been paid to the medical provider. The remaining balance from the insurance companies will then be billed to the patient who received the care until the facility that performed the work is adequately reimbursed for their services.

What Is the Downside of Traditional Medical Billing?

While the process of medical billing may seem straightforward on the surface, it doesn’t typically give organizations a broader view of revenue cycles or a company’s financial stability. It can also be slow and tedious, requiring the entire medical billing staff to organize and implement effectively. To streamline this process and improve processing procedures, many healthcare practices have turned to RCM (revenue cycle management) tools to increase billing accuracy and overall earning potential.

What Is Revenue Cycle Management (RCM)?

Revenue cycle management (RCM) encompasses all of the financial processes involved with a patient’s medical appointment. RCM is highly detailed, organized, and efficient throughout the complexities of medical billing. These tools therefore can give healthcare providers a better look into the flow of money involved for each party involved in the collections process. Some financial transactions that RCM helps to administer include:

• Payer contracting
• Coding
• Medical collections
• Provider enrollment
• Management
• Compliance
• Analytics

What Are the Four Key Steps of RCM?

RCM can go above and beyond what typical medical billing can do. To capture the revenue cycle management process at a higher level, here are the four key steps involved in the payment processing system.

Step #1: Capture Patient Payments

After a patient leaves a medical facility, it can sometimes be difficult to receive a payment from them. It may seem like a simple step in the process, but having an automated tool or outsourced team to help record each payment can improve the individual collection system for patients. RCM systems can train staff on how to properly collect payments from patients or even set up an online payment system to make it easier for patients to access.

Step #2: Receive Insurance Collections

Insurance collections are a part of the process that is similar to traditional medical billing that most organizations are familiar with. Revenue collection management can ensure that all insurance claims are accurately processed, and if any denials in payment come through, they can be resubmitted. This process helps confirm that the services have been coded correctly for all parties involved.

Step #3: Generate Revenue for Your Facility

To keep the lights on and healthcare workers paid fairly, you will need to generate revenue for your facility. As patients in the public use your services, each service (or outsourced, contracted service) needs to be credentialed or coded correctly so all revenue streams from insurance companies to individual patients can be processed effectively.

Step #4: Improve Processes With Accurate Reporting

The last step is procedural adjustment and reporting. RCM takes medical billing further by going through the small details and personalized patient adjustments so they can be reported seamlessly. This reporting saves healthcare staff time and can help bring in additional revenue to a healthcare facility.

Is RCM Right for My Practice?

If your healthcare practice is a small facility with minimal patients and staff, you may not need a robust billing system such as RCM. Traditional medical billing may suit your practice’s needs just as well. However, if you operate a large healthcare facility with many moving pieces involved in patient care, an RCM can drastically improve billing processes and put you in better financial shape for the future.

Meet CEO and Founder Adam Nager

Hi there, my name is Adam Nager. I’m the Chief Executive Officer and co-founder of Quest National Services.

What Is Quest National Services?

We’re a national, full-practice management revenue cycle management billing service. We cater to clients throughout the United States and almost 50 states nationwide.

Medical Billing for Our Clients

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Quest’s Healthcare Mission

We have over 3000 people that work within our team all focused on billing and providing transparency to your cash flow.

Why High Standards Matter in Medical Billing

When managing a medical practice, financial health and operational efficiency rely heavily on accurate, timely billing. Partnering with a medical billing service that prioritizes excellence ensures you stay compliant, maintain cash flow, and reduce administrative burdens. Quest National Services sets itself apart by adhering to the highest industry standards. Here’s how our commitment to quality helps your practice succeed.

Achieving Industry Benchmarks for Financial Performance

Achieving industry benchmarks is crucial for your practice’s long-term success. Quest National Services helps ensure your accounts receivable, collections, and denial rates align with or surpass MGMA (Medical Group Management Association) standards, giving you confidence that your financial operations meet industry expectations.

Optimized Revenue Cycle

An optimized revenue cycle improves cash flow and overall financial health. Quest National Services evaluates every aspect of your billing process, from claim submission to reimbursement, identifying areas for improvement to ensure faster payments and increased profitability.

Minimizing Claim Denials and Rejections

Denied claims can disrupt your revenue flow and increase your administrative workload. Quest National Services prioritizes accurate billing and coding to minimize the risk of denials, so your practice can focus on growth rather than resubmitting claims.

Accurate Billing and Coding Practices

By ensuring that claims are properly coded and documented from the outset, Quest National Services helps reduce costly rejections. Their expertise in coding compliance ensures claims are processed smoothly, leading to faster approvals and fewer corrections.

Efficient Authorization and Eligibility Management

Authorization and eligibility issues are common causes of claim rejections. Quest ensures that all necessary verifications are completed correctly the first time, reducing the risk of denied claims due to administrative errors and ensuring a more seamless patient experience.

Ensuring Compliance With Industry Standards

Maintaining compliance in an ever-changing regulatory landscape can be overwhelming. Quest National Services keeps your practice up to date with industry regulations, helping you avoid fines, audits, and other legal risks.

Expert Compliance Support

Quest’s billing team is well-versed in federal and state regulations, payer requirements, and medical coding updates. This expertise helps protect your practice from compliance issues and ensures adherence to legal and contractual obligations.

Stay Informed With Timely Communication

Staying updated on billing progress and potential issues is vital for maintaining control over your revenue cycle. Quest National Services provides regular updates and transparent reporting to keep you informed every step of the way.

Proactive Updates and Detailed Reports

Frequent communication and detailed reports provide valuable insights into your practice’s financial health. This level of transparency allows you to identify trends, address potential challenges early, and make informed financial decisions.

Educational Support for Your Team

Understanding the reasons behind claim denials and rejections empowers your team to make informed decisions. Quest National Services not only handles billing but also provides valuable feedback to help your team improve internal processes.

Training and Feedback for Process Improvement

By explaining the root causes of denials and providing actionable insights, Quest helps your team make adjustments that lead to long-term improvements. This collaborative approach reduces errors and strengthens your billing operations.

Customized Billing Solutions

Every medical practice has unique needs, and a one-size-fits-all billing solution rarely leads to optimal results. Quest National Services offers tailored billing strategies that align with your specific goals, specialty, and growth plans.

Adaptable Solutions for Growth

Quest’s services scale with your practice, whether you’re adding new locations, expanding your services, or navigating a changing patient base. Their customized approach ensures that your billing system remains efficient, no matter the size or complexity of your operations.

Improved Cash Flow and Faster Reimbursements

Maintaining consistent cash flow is essential for covering operational expenses and investing in growth. Quest National Services focuses on submitting clean claims quickly, leading to faster reimbursements and a more stable financial foundation.

Streamlined Billing Processes

Quest’s team works to streamline your billing workflows, reducing delays and bottlenecks. This ensures that reimbursements are received promptly, improving cash flow and giving your practice the financial flexibility to focus on delivering quality patient care.

Dedicated Support Team for Immediate Assistance

Billing issues can arise at any time and require prompt attention. Quest National Services provides a dedicated support team that is available to address your concerns and resolve challenges as they occur.

Responsive and Reliable Assistance

With a knowledgeable team just a call or email away, you can rest assured that your billing concerns will be addressed quickly. This reduces downtime, prevents billing disruptions, and ensures your practice stays on track financially.

Data-Driven Insights for Strategic Decisions

Accurate data is crucial for making informed financial decisions. Quest National Services provides comprehensive reports and analytics to give you a clearer picture of your practice’s financial performance.

Detailed Financial Reporting

Quest’s data-driven reports highlight trends, identify areas for improvement, and provide actionable insights. By understanding your financial performance, you can implement strategies that lead to sustainable growth.

Scalable Services for Long-Term Growth

As your practice grows, your billing needs will become more complex. Quest National Services offers scalable solutions designed to grow with you, ensuring that your billing processes remain efficient regardless of size or scope.

Flexible Billing Solutions

Whether you’re adding new providers, locations, or services, Quest’s adaptable solutions ensure your billing system continues to operate at peak efficiency. Their flexible approach supports your growth without compromising performance.

Reliable Partnership With Transparency

A strong partnership with a trusted billing service provider can make a significant difference in your practice’s success. Quest National Services fosters a collaborative, transparent relationship that ensures you always know the status of your financial operations.

Building Trust Through Transparency

Quest’s commitment to transparency means you’ll receive clear communication, detailed reports, and proactive updates. This builds trust and strengthens your confidence in their ability to support your practice’s long-term goals.

Focus on Patient Care by Reducing Administrative Burden

Outsourcing your billing operations to Quest allows your team to spend less time on administrative tasks and more time on patient care. This not only improves patient satisfaction but also reduces the risk of staff burnout.

More Time for What Matters Most

By handling the complexities of medical billing, Quest frees up your internal team to focus on delivering exceptional patient care. This improves overall practice efficiency and enhances the patient experience.

Minimized Financial Risk

Financial instability can have serious consequences for your practice. Quest National Services minimizes your financial risk by adhering to proven billing standards and best practices, ensuring a steady revenue stream.

Protection From Revenue Loss

With accurate billing, proactive denial management, and adherence to industry regulations, Quest helps safeguard your practice from revenue disruptions and financial setbacks.

Competitive Advantage in the Healthcare Market

A strong financial foundation can set your practice apart from competitors. Quest National Services helps strengthen your practice’s financial health, making it easier to invest in technology, staff, and expanded services.

Investing in Growth and Innovation

With more predictable revenue and faster reimbursements, your practice can reinvest in areas that improve patient outcomes and enhance your competitive edge. This positions your practice as a leader in the healthcare market.

Continuous Improvement for Long-Term Success

Quest National Services is committed to continuous improvement, ensuring that your billing processes remain efficient and compliant with industry changes. This proactive approach helps your practice stay ahead of the curve.

Ongoing Service Enhancements

Through regular process updates, technology improvements, and compliance checks, Quest ensures that your billing system evolves with the industry. This keeps your practice agile and resilient in a dynamic healthcare environment.