In the world of medical billing, the tiniest details can make the biggest difference—especially when it comes to modifiers. Two of the most commonly misunderstood are modifier 25 and modifier 59. To the untrained eye, they may seem interchangeable. But in reality, using the wrong one could trigger denials, audits, or even compliance issues. If … Read more
Modifier 23 means “Unusual Anesthesia.” It’s appended to a surgical procedure code to indicate that anesthesia services were more extensive than typically expected due to unusual circumstances. CPT Definition: Modifier 23 – Unusual Anesthesia: “When a procedure which usually requires either no anesthesia or local anesthesia must be done under general anesthesia due to unusual … Read more
While medical coders and billers both contribute to the healthcare revenue cycle, their roles serve different but complementary purposes. Medical coders translate doctors’ notes, test results, and procedures into standardized codes like ICD-10 and CPT. These codes are essential for insurance documentation and accurate patient records. In contrast, medical billers take those codes and prepare … Read more
Whether you’re a student learning medical billing, a healthcare provider, or a patient reviewing your surgical charges, understanding the difference between global periods and postoperative care billing can help you avoid confusion and billing errors. Where to Learn About Global and Postoperative Periods If you want reliable, up-to-date information on surgical billing rules, start with … Read more
In medical billing, the terms “clean claim” and “dirty claim” are more than just jargon—they directly affect how quickly healthcare providers get paid. A clean claim is one that is accurately completed, properly coded, and submitted in compliance with the payer’s guidelines. It processes smoothly and typically results in timely payment. A dirty claim, by … Read more
In medical billing, authorization and referral serve different purposes, though both are crucial for insurance coverage and patient care. Simply put, authorization is permission from the insurance company for a service, while a referral is a recommendation from a primary care provider (PCP) to see a specialist. Let’s break down the details to help you … Read more
In the evolving landscape of healthcare documentation and reimbursement, understanding the key differences between ICD-10-CM and ICD-10-PCS is fundamental for medical coders, billers, and healthcare administrators. While both coding systems are integral to the broader ICD-10 classification, they serve distinct roles. This comprehensive guide will clarify their uses, structures, and importance in modern healthcare. What … Read more
Copay is a fixed amount you pay for a healthcare service—like $25 for a doctor visit—while coinsurance is a percentage of the total cost of care you pay after meeting your deductible—like 20% of a $1,000 procedure. Both are forms of cost-sharing but work very differently. Understanding Copay: Fixed, Predictable Payments Copay (or copayment) is … 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
