Medical billing is the process of submitting claims to insurance companies or patients for reimbursement of medical services, involving coding, claim generation, and following up on payments to ensure healthcare providers get paid.
Upcoding and downcoding are billing practices in medical coding—but they have very different implications.Upcoding is when a healthcare provider uses billing codes for more severe diagnoses or procedures than what was actually performed, often to receive higher reimbursement. Downcoding, on the other hand, is when the billing code reflects a less severe or lower-cost service … Read more
When you visit a doctor or hospital, your out-of-pocket cost often depends on whether your provider is participating or non-participating with your health insurance plan. Simply put: Understanding the difference can save you money and stress—especially when unexpected medical bills appear. Participating Providers: What You Get These providers have signed agreements with insurance companies. This … Read more
The Electronic Remittance Advice (ERA) and the Explanation of Benefits (EOB) both explain how a healthcare claim was processed—but they serve different audiences. EOBs are typically sent to patients by their health insurance provider. In contrast, ERAs are sent electronically to healthcare providers to explain the payment and claim status. 🧾 What Is an EOB? … Read more
In simple terms: A deductible is the amount you must pay for covered health services before your insurance starts paying. The out-of-pocket maximum is the most you’ll have to pay in a year — after which your insurance covers 100% of covered costs. Both terms are key to understanding how much you’ll spend on healthcare … Read more
Z codes in the ICD-10-CM system stand out because they don’t represent diseases, but rather reasons for healthcare encounters that affect a patient’s overall health or well-being. While traditional ICD-10 codes reflect diagnoses, Z codes document social, behavioral, and environmental factors, which can be vital in holistic treatment planning and preventive care. 🧠 What Are … Read more
Bundling in CPT coding means combining multiple services into one code for billing, while unbundling is separating them out to bill each individually.Bundling is often required to follow payer rules and avoid overbilling, while unbundling (when appropriate) ensures every provided service gets recognized. Correct usage protects against claim denials, audits, and compliance risks. What Is … Read more
Understanding these distinctions ensures accurate billing, compliance, and maximum reimbursements. 1. CPT Category I Codes: The Foundation of Medical Billing Purpose: Used for established medical, surgical, and diagnostic services.Examples: Why They Matter:✔ Required for insurance claims.✔ Directly tied to reimbursements.✔ Updated annually by the American Medical Association (AMA). Common Challenges: 2. CPT Category II Codes: Tracking Quality … Read more
Navigating health insurance claims can be complex, especially when patients have multiple insurance policies. Understanding the difference between primary and secondary insurance is crucial for accurate billing, timely reimbursements, and minimizing claim denials. This article explores the distinctions between primary and secondary insurance, their importance in healthcare billing, key processes involved, and the benefits of outsourcing medical … Read more
Denial Code 18 signifies that the insurance payer has rejected the claim because it appears to be a duplicate submission. This occurs when a provider submits the same claim multiple times, whether intentionally or unintentionally, before the original claim has been fully processed. Common Causes of Denial Code 18 Several factors contribute to Denial Code … Read more
