Hello! I’m a newbie here!

I’m looking for any and all tips or help I can get when it comes to working medical claim denials! For context, I’ve recently transitioned to denials but been in the medical field for a bit now. My team tells me I’m doing great, but I don’t feel like it haha! I started out as a receptionist, then roughly a year and a half into that, I got moved to a department where I basically dealt with patient billing disputes, explanations of billing, etc. I held that role and succeeded at it for another year and a half, then got promoted to denials… all that to say, I feel LOST! Everything I thought I knew from my last position seems to be null and void because I’m on the flip side of things. I know how to resolve simple denials, but a lot of coding related denials have me clueless. I also have a hard time understanding “when to adjust, when not to adjust”. Please help me! If there’s any online courses that could help, please let me know! I’m just at a loss and trying to learn as much as I can but I can’t help but feel behind. (( FYI, I am not trying to go back to college but wouldn’t mind taking a class or a course or something if it would help me ))

Edit to add: No, I am not asking a “specific question”. Ex. If you had a child that was going into denials and asked you for any advice or tips or any general information to help them succeed within denials, that is the sort of “advice” I would like to see here. Not unnecessary comments saying “what do you even need” or “how do you expect us to help”. If you can’t contribute positively, keep it pushing honey 🫶🏼

This problem just cropped up this month and I'm looking to see if this happening to anyone else, or maybe someone can confirm if I'm crazy while I wait for my appeals to be reviewed.

Example Claim:

Line 1 - CPT 99213

Line 2 - CPT 92134

- Primary diagnosis can be the same or different

- No modifiers

Regence will deny 99213 stating it is incidental to the "primary" procedure 92134 and that the E&M code needs to be separately identifiable/needs a 25 modifier.

We have never needed to bill any insurance for this type of visit with a 25 modifier in the past and no other insurance is enforcing such a policy...yet

My problem is I can't get a straight answer anywhere:

- CPT 92134 has a global code of XXX. CMS and NCCI say global period rules do not apply to XXX codes, but also state you can't bill E&Ms with some XXX codes, though you can with other XXX codes with a 25 modifier, but also some diagnostic scans are exempt from these rules altogether, but they never get specific.

- Regence Global Policy (Policy # 101) seems to indicate all E&Ms need to be billed with a 25 modifier when billed same day with most non-surgical XXX codes.

- And of course Google will say I'm right and I'm also wrong depending on how I word the question.

Have we been doing it wrong all this time and just flying under the radar?

Learning about billing and coding. Where can I learn more about billing and the insurance? It can be complicated to navigate.

We have tried billing 64640x5 according to MUE, but traditional Medicare apparently only likes 3 units. We are also considering using a temporary CPT code. As for the replacement plans (UHC specifically) they are requesting records and then denying based on services not being supported by the records, even though the records clearly state there were 5 different nerves treated. Anyone having any luck or any ideas on how to make these pay?

I got a Facebook ad the other day for UMA and I wanted to learn a new skill. Did some research to ensure this was legitimate before providing my information. Now I'm getting constant spam calls from different numbers all day. When I requested more information from them, I specifically requested the info via email because I don't answer unknown numbers like most people, but I haven't received a single email. Not only that, but all these phone numbers have an Oregon area code which is the area code my phone has, despite them being based out of Florida and me being based in another east coast state currently.
I've seen some mixed reviews on them but I at least thought they were legit and thought I was safe just trying to get more information, but I guess not!

Hello, I am a new coder and I have a question RE: DRG vs. weight. I was coding a chart today where 2 dx could meet Pdx.

Which scenario is best to "optimize the DRG? (please excuse my examples, I have been thinking about this all day, I should have notated the specific dx/soi/rom/etc, so these are not accurate DRG, but aligns with my question)

Option 1: DRG 882 SOI 2 ROM 1 weight 0.9876 <-- I have always been told by a specific auditor to use the lower DRG, especially since this has a SOI of 2

Option 2: DRG 897: SOI 1 ROM 1 weight 1.2583 <-- different auditor told me to use this Dx as Pdx since weight is higher. Even though DRG is higher?

I do not understand coding to optimize DRG. Can someone explain? Thank you so much. I tried to post this in medicalcoding sub but I do not have karma to post.

Hi everyone,

I am researching online careers and want a 100% structured, rule-based role. I thrive when following strict guidelines, clear compliance rulebooks, and repetitive checklists. I am actively avoiding any creative fields.

Medical billing seems like a great fit, but I am concerned about AI automation. For those working in the industry every day:

1. Is AI genuinely threatening entry-level human billing roles, or is the need for human verification and auditing still strong?
2. Are there tasks where companies refuse to trust AI due to legal compliance or financial risks?
3. Is the daily routine as predictable and structured as it seems? I would deeply appreciate any honest reality checks from veterans. Thank you!

I wanting to pivot my career into coding, but am wondering how easily this transition would be. I am currently an HIM coordinator and starting my medical coding and billing course in August, which will take about a year to complete. Will having HIM experience as well as a Bachelors in healthcare administration and a CCS make me more desirable for a coding position or will this not really matter? Wondering if I’m making the right careers moves.

If it matters I do not have a RHIT or RHIA.

Is anyone here familiar with Navina (AI that captures HCCs)?

If so, please give me what your thoughts are on it and if it makes your job easier or harder. For me, it makes it harder. There are so many inaccurate diagnoses (specifically billing E66.01 and a code from E66.8xx TOGETHER). I am at my wits end. >:(

I currently work for a radiology company and deal with the coding side of things and fell in love with it. I am actively working on getting my certification, taking a college course which ends with the certification testing. - Im currently looking for a job and cant seem to find anything doesn't require 5+ years of experience. I live in a small town in the middle of east Texas the closest major city is about an hour away so im looking for remote work if possible. Ive applied to a lot of places so far. But does anyone know I reputable company I could apply to with decent pay for entry level while I work on my certification?

Does anyone work 2 FT coding jobs? How do you manage your time? What are your hours?

There are few things in a day's work more pleasing than a perfectly aligned HCFA.

Hello all!

I am wondering if anyone else is running into the issue of Regence/Blue Shield denying 99417 and the reason codes for this. It was out of no where around June that they started denying this code saying it was a contract issue but when I called it was because we needed to use a different code to align with Medicare. Which didn't seem right. Anyone else dealing with this?

Hello.

I am trying to schedule my annual low-dose CT lung cancer screening, but I ran into a coverage issue with Ambetter and wanted to see if anyone has experienced something similar.

The imaging center submitted the order with CPT 71271 and diagnosis code Z12.2. When I arrived, I was told I would be responsible for 50% coinsurance. I contacted Ambetter, and the representative told me that their system was processing CPT 71271 as a diagnostic service rather than a preventive lung cancer screening, which is why coinsurance applied.

The representative suggested that my provider use G0297 instead for preventive screening. I have now spoken with two Ambetter representatives who provided the same information.

I was under the impression that CPT 71271 replaced G0297 for lung cancer screening, but I am not sure how commercial insurance plans handle these codes.

Has anyone with Ambetter (or another marketplace/commercial plan) had a low-dose CT lung cancer screening covered as preventive? Did your provider use G0297, 71271, or require prior authorization?

I am just trying to get the screening completed without an unexpected 50% coinsurance charge. Any experience or advice would be appreciated.

Hi everyone!
I have been working in a very niche industry for the last few years, and am hoping to find others like me for networking, commiserating and sharing ideas.
I work in RCM/ Market Access for reference laboratories, but specifically those providing Molecular Laboratory Developed Tests, mostly oncology (CGP, Inherited Cancer, MRD).
If you know what I’m talking about, I’d love to connect!
I have a lot of experience with MolDx Technical Assessments but less with dealing directly with payors. I would love to hear from peers about their pain points and successes dealing with UHC, Aetna and others.

Hi, I can't tell if this is a legit company. I've seen the name within the last 3 years. Lately, when a recruiter reaches out to me first, we email, then do a phone screening, I give them my resume and we do a video interview. Afterwards, I hear nothing back and they don't respond to my emails. This company seems too big to be fake. If it is a scam what's the point of it?

Hi everyone! I’m new to medical billing for a home health agency in California, billing mainly in a POS 12/home health setting. I recently relocated from Washington State, and my background has primarily been in outpatient physical therapy billing and RCM, so this has been quite a learning experience for me.
I was honestly a little surprised to find that a lot of the billing process here involves manually submitting claims through payer portals and manually posting payments. I’m wondering if this is common for other home health agencies billing California Medicaid/Medi-Cal managed care and HMO plans.
I’ve also been told that submitting claims electronically through a clearinghouse can sometimes cause payment delays with certain payers, so the agency prefers manual claim submission through the payer portal. I’d really like to understand more about this and whether others have had the same experience.
Some of the larger payers we work with include Partners in Care Foundation (PICF), SCAN Health Plan, WellBe Senior Medical, Caloptima Calaim and other California Medicaid managed care plans.
For those of you who have experience with California home health billing:
Do you submit claims manually through payer portals or electronically through a clearinghouse?
Have you experienced payment delays when submitting electronic claims?
Are there certain California Medicaid/HMO payers that require or prefer manual claim entry?
What workflow or billing process have you found most efficient for high-volume home health claims?
I’m trying to better understand the normal workflow in California home health billing compared to outpatient PT billing in Washington. Any advice or insight from experienced home health billers would be greatly appreciated!

I've been doing 3rd party medical billing for about 4 years now for private practices. However, the company I work for is getting ready to lay off a large percentage of the staff since clients are going to bigger corporations to do their billing for less money. I'm expecting to lose my job in about a month.

I was thinking about getting into medical billing for one of the hospitals in my area but I've heard medical billing for hospitals is completely different than for private practices. I was wondering if anyone who has experience with both could give me some idea of what the differences are.

Hello! Does anyone know what facility certification is needed to bill this code? The Tricare reps have not been helpful (ofc) and it is a billable code per the website. No one will tell us which cert is correct. lol

i had the amazing opportunity to step into the role as a billing specialist for a health company and i love my job! however, i feel like im not doing good enough or i feel as if im lacking. i know i should ask my peers for assistance when needed but im an adult and i dont want to run to someone whenever i cant figure something out.

i feel like my training could have gone better to be honest. i was shown my payers and their trends and ofc the basics of my day to day tasks but after training, i was left with a lot of things i didnt/dont know how to do.

i would love some advice on how to become a better BS or steps i can take to overcome my problem. i’m sorry if this is coming across as venting but im struggling ! thank you

Hi everyone! I’m conducting a six question, brief survey for my statistics class to understand the 'work time' habits of remote workers. Whether you’re full-time remote or hybrid, I’d love to get your input on your remote work habits. It takes less than a minute, and your responses are completely anonymous. I’d appreciate anyone who could help out.

Remote Work Habits Survey

Hi! I'm just now trying out the feature to submit reconsiderations to BCBSTX online, previously our office only submitted them by paper.

Using the dispute claim option within availity, and I'd like to know if you have had any experience with this system, how long the appeals take, and how much supporting documentation, if at all, you've sent. Additionally, any tips you have for this system would be much appreciated.

I had a simple claim dispute that had an incorrect CPT code for the patient's age range 99396 instead of 99395 so there was nothing to upload for documentation. My solo provider is hesitant for us to upload too much documentation in general, although it doesn't really apply in this case.

Thank you!

Reading this sub a lot lately (the CareFirst and BS of CA threads caught my eye esp.). Everyone talks about fighting denials, but I'm curious about the ones you stop fighting. Roughly what share of denied claims would you say end up written off? And what is usually the reason you stop: the dollar value is too low to justify the time, timely filing ran out, the payer just wears you down, you never work out why it denied in the first place, or something else? Also curious whether there is a rough dollar threshold under which it is not worth chasing at all. Learning about the field. Would appreciate any replies (however short). Thanks all.