How to Use J-Codes to Represent Various Medical Drugs and Services?


Healthcare Common Procedure Coding System (HCPCS) is based on Current Procedural Terminology (CPT) developed by Center of Medicare and Medicaid (CMS). Till 1996, HCPCS was optional but after the passage of Health Information Portability and Accountability Act (HIPAA), the government had made the use of HCPCS mandatory in certain cases.

The HCPCS has divided the codes into two levels:

  • Level I: – Identical to CPT codes.
  • Level II: – To represent non-physician services like medical equipment, wheelchair, ambulance ride and other medical services.

HCPCS Level II codes or better known as J-codes are represented in the alphanumeric pattern. The first position is represented with an alphabet, while the next positions are occupied by numbers.

To understand the topic on J-codes we have prepared an informational and concise E-Book for the pharmacist. “How to use J-codes to represent various medical drugs and services?”

Click here to grab a free Copy of your E-book now!

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Why you May Not are Receiving Reimbursement for ASC Medical Billing?


ASC medical billing widely known as Ambulatory Surgery Centre is different from the rest of the billing process. Before you go forward, it’s important to know what ASC is all about.

Ambulatory Surgery Centre is a facility which simply specializes in outpatient procedures which may include procedures like surgeries, pain management, or diagnosing procedure like colonoscopies etc. Usually, the procedure performed at ASC are extensive than the typical ones; also they might require an overnight stay at a hospital.

ASC is not a medical specialty….it doesn’t revolve around specific services, diagnosis or procedures. ASC billing and coding uses all same codes, billing techniques and many of the same billing and coding guidelines by the entire medical industry.

Hospitals use UB-04 claim form, doctor’s offices and other outpatient healthcare providers use the CMS-1500 form. In this case, ASCs are no different and use the typical provider form.

Ambulatory Service Centres are like having every medical specialty all rolled into one.

You can go there for a cast, a colonoscopy, or for surgical dressings. But, you can’t go there for a sick visit and get a diagnosis from a primary care physician. ASCs only provide services to those who already have a diagnosis from a primary care physician, and who need medically necessary procedures performed.

Knowing ASC Billing and Coding

ASC billing uses a combination of hospital and physician billing. However; ASCs use CPT and HCPCS Level II codes to bill most of their services, some payers will allow an ASC to bill ICD-9-CM procedure codes like hospital. Some payers even base implant reimbursement on revenue code classification.

It’s important to use the proper form when submitting claims. Medicare pays for ASC services under Part B and requires the CMS-1500 claim form. Some third-party carriers will accept the CMS-1500 form, while others allow the UB04. To avoid errors in ASC medical billing it is advisable to hire outsourced ASC billing services.

ASC requires focused billing and coding. Below mentioned are significant things to know in which you may not be receiving reimbursement for ASC medical billing:

  1. You may lose your money if your codes are not in right order

Once you have referenced the operative report and you know which codes to bill for, it’s essential to put your codes in the right order. Make sure you record your codes from highest reimbursement to lowest reimbursement so that you don’t lose money unnecessarily. It may be possible to correct your reimbursement if you make this mistake, but it is recommends doing it right the first time to save yourself a lot of hassle.

  1. Medicare will not reimburse for those treated in skilled nursing facility

ASCs that have previously treated patients from skilled nursing facilities will most likely be subject to reimbursement take backs for procedures that occurred since Jan. 1, 2008. While there’s nothing ASCs can do to combat this decision, you should still prepare yourself for the setbacks by identifying your skilled nursing facility patients.

  1. HIPAA-exempt carriers who doesn’t uses standard codes

Your ASC should be aware of carriers who don’t follow standardized coding practices because of HIPAA exemption. Worker’s compensation carriers, small carriers and other carriers that are HIPAA-exempt can come up with home-grown codes, and you’re not going to get paid if you use standardized codes.

 To avoid having your claims rejected, make sure you know whether your carrier is exempt.

  1. Your managed care contract is important

Your biller should have a copy of every managed care contract and you need to understand how long you have to submit a claim, how long you have to review an adjudicated claim, what the payment methodology is, why a carrier would reduce multiple procedures and how to appeal a claim that hasn’t been paid correctly.

Your ASC should use your managed care contract to bill out, post payments and follow up, and you need it at every point of the revenue cycle.

ASC physicians can’t afford for codes to be entered incorrectly or incompetently. They can’t afford delays in payment or financial uncertainty. ASC physicians must make sure they’re reimbursed for every dollar they are owed in a timely fashion; hence outsourcing to ASC billing company Ohio can help from financial fallout.

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The True Cost of Medical Billing and Coding Services

Today’s ambiguous economic conditions are presenting healthcare practices across the US with a whole host of challenges. These include complex patient procedures, increased competition, the pressures from altering regulations, and declining reimbursements, all of which negatively affects your bottom line. This prompts you to find ways to cut costs and improve efficiency, and what better option than a specialty medical billing and coding organization. The majority of medical practices are paying too much for their medical billing.

Go through the following Info graph and find out the true cost of medical billing and coding services.

The True Cost of Medical Billing and Coding Services

Posted in Accounts Receivables, Medical Billing, Medical Coding, Practice Administration, Practice Management, Revenue Cycle Management (RCM) | Leave a comment

Understanding Medical Coding Modifiers in Orthopedic Specialization

Understanding Medical Coding Modifiers in Orthopedic Specialization

Problems like injuries, congenital deformities or abnormalities and diseases concerning the musculoskeletal system fall under the purview of orthopedic treatments. Regardless of the nature of orthopedic specialization your clinic excels at successful billing practices demand that your medical billing specialist is well versed with fulfilling the coding demands relative to the specialty field.

Correct interpretation of information and proper application of codes, modifiers, and extensions facilitates creation and flawless functioning of a proper revenue stream for the practice by minimizing claim rejections and denials. Following the guidelines put forth by CMS (Centers for Medicare and Medicaid Services), our orthopedic specialist coders provide billing services that pump up your revenue cycle.

The implementation of ICD-10 brought around with it 264 new codes, 143 deleted, and 134 revised codes that apply to coding for an orthopedic practice. New rules related to modifier 59 and the introduction of the applicable modifiers XU, XE, XP, and XS are here to revolutionize orthopedics billing from here. Our team of skilled medical billing professionals display their understanding of the ICD-10, and proficiency at numerous ways in which the new requirements and coding changes impact orthopedics.

What Are Modifiers & Why Are They Game Changers in orthopedics billing?

By definition, Modifiers are simple two-character designators that signal towards a change in how the code for the procedure or services should be applied for the claim. If put to use strategically, modifiers add on to the accuracy and detail to the record of the medical encounter. If misused, they can lead to claim denials, payer audits, and in rare cases investigations, refunds, and fines.

Modifiers are two digit codes and are categorized into two levels:-

  1. Level I Modifiers: Normally known as CPT Modifiers and consists of two numeric digits and are updated annually by AMA – American Medical Association. These CPT modifiers are used to additionally supplement information or adjust care descriptions to provide extra details concerning a procedure or service provided to a patient.
  1. Level II Modifiers: Also known as HCPCS Modifiers and these consist of two digits (Alpha / Alphanumeric characters) in the sequence AA through VP. These modifiers are annually updated by CMS – Centers for Medicare and Medicaid Services.

Obtaining the rightful revenue through your orthopedic requires detailed knowledge and use of code modifier wherever suitable and permissible. Modifiers are added to the main procedure code to indicate that the procedure has been altered by a distinct factor. Modifiers can increase or decrease reimbursement. They can also cause claims not to pay properly or deny if used incorrectly or not used, when necessary. Some modifiers are for use by Ambulatory Surgical Centers only, some for physician practices and some are for use by both provider types. Here is a concise table representing the use of modifiers in orthopedic services:

Modifier Procedure Unit (ASC/P) Condition
-50 Bilateral procedures Both
  • Used when an identical procedure is performed on both the right and left sides of the body.
  • Some payers prefer the use of the -50 modifier, and others require the use of the -RT anatomic modifier on one code and the -LT modifier on the other code.
  • Due to varied company policies, ASC facility should check with each payer to which they submit claims for their preferred method of billing bilateral procedures.
-51 Multiple procedures (P)
  • Use -51 when more than one procedure (excluding E&M codes) is performed on the same day during the same encounter by the same physician.
  • The exception to this guideline is if the CPT code is an add-on code, or if it is –51 modifier-exempt.
-52 Reduced services
  • This modifier is used to indicate that a procedure was partially reduced or eliminated at the physician’s discretion.
-58 Staged or related procedure or service by the same physician during the postoperative period Both Use this modifier to indicate the performance of a procedure or service during the postoperative period that was:

1.      Staged.

2.      More extensive than the original procedure.

3.      For therapy following a diagnostic surgical procedure.

-59 Distinct procedural service Both
  • Use this modifier to indicate the procedure or service was distinct or independent from other services performed on the same day, to identify procedures not normally reported together (due to CCI edits or “separate procedure” status in the CPT book), but which are appropriate under the circumstances or to represent a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion or separate injury not normally encountered or performed on the same day by the same surgeon.
  • This modifier may override edits in the payer’s system, which would normally deny the code (i.e., unbundling, etc.), but under special circumstances, the modifier can be used to make the service payable — thus, the -59 modifier has a higher audit potential with Medicare and other payers.
-73 Discontinued outpatient hospital/ASC procedure prior to the administration of anesthesia (A)
  • This modifier is appended to the CPT code for the intended procedure(s) to indicate that a procedure was terminated due to medical complications after the patient had been prepared for surgery and taken to the OR, but before anesthesia was induced.
-74 Discontinued outpatient hospital/ASC procedure after the administration of anesthesia (A)
  • This modifier is appended to the CPT code for the intended procedure(s) to indicate that a procedure was terminated due to medical complications after anesthesia for the procedure was induced.
-76 Repeat procedure or service by same physician Both
  • Use this modifier only if an identical procedure is being performed following the initial procedure.
-77 Repeat procedure or service by another physician Both
  • This modifier is used in the situation where a physician repeats a procedure that had previously been performed by another physician.
-78 Return to the OR for a related procedure during the postoperative period Both
  • This modifier will result in reduced reimbursement for the physician as the payment will reflect the surgery component only. However, failure to use this modifier, when necessary, will probably result in a claim denial.
-79 Unrelated procedure or service by the same physician during the postoperative period Both
  • This modifier is to be used to indicate that an unrelated procedure was performed by the same physician during the postoperative period.
-RT & -LT Right Side and Left Side Both
  • If you bill a procedure that will be done bilaterally without the modifier for that side, when you bill the other side later, it may (needlessly) be denied as a duplicate claim, which will have to be appealed.
-TC Technical component Both
  • The –TC modifier reflects that the technical component only of an X-ray is being billed for by the ASC. This is billing for the taking of the X-ray or use of fluoroscopy by the facility.
-F3 &






Left hand, thumb

Left hand, second digit

Left hand, third digit

Left hand, fourth digit

Left hand, fifth digit


Left foot, great toe

Left foot, second digit

Left foot, third digit

Left foot, fourth digit

Left foot, fifth digit

  • Do not use –RT or –LT modifiers with these codes. Also, it is not necessary to use -59 modifier with the digit modifiers unless you need to report more than one procedure on the same toe or finger when it is separately billable.



-T5 -T6 -T7 -T8


Right hand, thumb

Right hand, second digit

Right hand, third digit

Right hand, fourth digit

Right hand, fifth digit

Right foot, great toe

Right foot, second toe

Right foot, third digit

Right foot, fourth digit

Right foot, fifth digit



-SG ASC facility service (A)
-GA Waiver of liability on file Both
-GY Statutorily excluded Both

Posted in EMR / EHR / Health IT, Health Insurance, Healthcare Reforms, ICD-10, ICD-10 Coding, ICD-10 Testing, Infographics, Medical Billing, Medical Billing & Coding jobs, Medical Coding, Orthopedic Billing, Physicians/ Doctors, Practice Administration, Practice Management, Revenue Cycle Management (RCM), Why Outsource Medical Billing Services | Tagged , | Leave a comment

Are you able to avoid these common Ophthalmic Billing Rejections?

Are you able to avoid these common Ophthalmic Billing Rejections?

Working as an ophthalmic specialist has its own advantages and disadvantages. The plus point of being an Optometrist is that as a profession it’s a very decent industry for your growth as a practitioner, but the negative side of it is delayed and denied reimbursements, prolonged AR days, negative collections, billing rejection and slow paced income cycle, due to incorrect billing and coding.

Some of the common Ophthalmic Billing Rejections happen due to the following things:

Audit Medicare and Insurance Companies Policies

Remember to dependably check with your Medicare provider or other insurance agency’s strategies for the latest coding rules; they change as frequently as each year passes. Furthermore, Medicare’s National Correct Coding Initiative (NCCI) edit tables can be found on the CMS site.

Correct coding gets you paid

Numerous ophthalmic facilities charge an OCT/GDX (CPT codes 92133/92134) and fundus photography (CPT code 92250) on a same visit. If you don’t code this accurately, Medicare may deny both codes or only permit payment on the code with the most minimal repayment. If you are looking at a single issue such as glaucoma, both tests cannot be paid per Medicare’s NCCI edits; codes 92133/92134 and 92250 are considered mutually exclusive.

Utilize Modifier 59 Correctly to avoid fines and audits

Modifier 59 characterizes a Distinct Procedure Service and distinguishes methods or administrations that are not typically revealed together. In any case, modifier 59 is one of the most used modifiers and furthermore one that is frequently utilized erroneously.

Tip: Never attach modifier 59 to E&M benefits.

Contingent upon the local policy, if the tests are essential because of two independently identifiable conditions, you might have the capacity to connect the proper diagnosis code to each CPT and add modifier 59 to the second procedure. It is essential to stay aware of Local Coverage Determinations (LCD) for your region to ensure you are coding claims effectively.

Claim Scrubbing edits help maintain delays in Reimbursements

Some practice management system do exclude features that supports claim scrubbing edits that alert you referring or requesting a doctor. What is the outcome? Claims are sent to insurance agencies with blunders/errors, causing rejections and delays in the reimbursement cycle. Certified Ophthalmic medical billers and coders are specialists at ensuring your claims are perfect and free from mistakes. They realize that being effective and knowing how to keep those rejections at bay and to get reimbursed faster. That’s why they double check and scrub every claim before submission. As a result, optometrist avoids delays in payments, a key benefit of using offshore medical billing company’s help.

Next in the list of common billing rejection are the issues to bill new and established patients.

So, when is the patient new or established? And how can his/her claim get rejected?

A patient is viewed as new in the event that they have not been seen by any doctor with a similar specialty or sub-specialty within their practice for the last three years. For solo insurance providers this is simple, if the patient hasn’t been treated by them for the last three years, they’re subjected as new. However, for larger group practices, it can get dubious. Keeping legitimate records with the help of a proficient Ophthalmic billing company can keep those common group practice billing rejections at bay.

During some instances, an insurance payer may incorrectly reject a claim for a new patient. However, if you have an expert billing agency assisting you in the operations this can be resolved with a phone call to the payer, though some cases may require an appeal with medical documentation.

Posted in Accounts Receivables, Claims Denials, EMR / EHR / Health IT, EMS Billing Services, Health Insurance, ICD-10, ICD-10 Coding, ICD-10 Testing, Infographics, Insurance / Payer, Medical Billing, Medical Billing & Coding jobs, Medical Coding, Medical Equipment, Medicare Medicaid, Physicians/ Doctors, Practice Administration, Practice Management, Revenue Cycle Management (RCM) | Tagged , | Leave a comment

5 Tricks in Medical Practice’s to improve your Accounts Receivable

5 Tricks in Medical Practice’s to improve your Accounts Receivable

Insurance companies are increasingly inventing complex and new set of rules for the medical procedure which has resulted into loads of denials and underpayment.  Doctors and pharmacist are increasingly finding it difficult under the ever-changing federal laws for practice and drugs. The recent data will also show the plight of doctors.

Unpaid Amount

Only 70% of the claims submitted are paid first time according to the research Center of Medicare and Medicaid (CMS). The other 30% denied claims are either lost or ignored or never resubmitted. Out of those 30% denied claims 60% claims are never resubmitted.

What’s more shocking is the fact that doctors aren’t even paid in full according to their contracts. The medical group management association (MGMA) estimates that payers are currently underpaying the doctors by almost 7% to 11%. So on average, a doctor is not paid 25% of their amount that they have earned by treating a patient. This has translated to a total of $125 billion left on the table by American Health Care industry.

Currently, doctors are shifting away from private practices as the sustainability on lone basis is difficult with the requirement of software’s and extra staff for revenue cycle management.

With unpaid and underpayment doctors are looking for innovative ways to approach the problem. Here are certain methods to use which you can amplify your ARs.

Claim submission management

If the submitted claim is not paid up in the first submission cycle the likelihood that the claim will ever get paid also reduces drastically. One of the best methods to get paid when the claim is submitted is to identify the potential claim which might be rejected.

Identifying such claims using an intelligent engine that constantly adapts and updates according to the rules and regulation of payers. 

Using a software solution to constantly update and adapts after analyzing all the denied claim of the insurance company from all doctors.

Payment Tracking

One of the major problems with doctor’s payment is the underpayment. Now every doctor has a different contract with each payer or insurance company.

Now if four people come in with a same medical condition that needs same doctor but each patient has different medical insurance then each insurer pays a different amount.

For this, you need software to track all payments. You can allow the contracts which pay full payment or even used to predict future collections.

 Daily ageing of receivable

Traditionally receivable are tracked based on 30-day increment period. But now as each payer has a different schedule, they will need a different set of actions. Two receivables which are 30-day old could require different actions from different payers.

With no 30-60-90 days plan being followed a manual monitoring is needed for each claim. Practice can improve their days-sales-outstanding (DSO) with constant monitoring of all claims. The sooner practice follow-up with insurers the better chance you have of being paid than the claim being lost or ignored. Practice management software can help keep track of this without manually doing this work.

Work-flow management

From patient appointment scheduling to collecting reimbursement from payer requires a tedious process of documentation this all can now be done electronically with software. The manual work makes the process error prone and less efficient.

Every mistake in the documentation will be added on till the claim submission creating a bumpy ride for AR. Most efficient medical practices use practice management software to automate the workflow management.

Top notch software will schedule the patient visit for you, look through claim system for you and track all your AR from outsourced billers and coders. Send customized emails to patients informing them about their appointments.

Modern health care reporting and analysis

Modern health care industry is much based on making the right decision which can only be achieved with complete access, and well-organized data. Data can be your accomplice for growth if analyzed with purpose. Modern healthcare trends are important for achieving revenue growth.  This all can only be done when you have all your data at one place.

It is important for being able to mine data when you are on the go, so you can create reports and have live analysis. The process of data mining can be eased using practice management software providing you with UX to access data.

Things you should look into your practice management software

  1. Automate Work queue

The work queue will simply automate and update as your front desk will update the patients’ appointment. The doctors can reschedule or provide confirmation on the same appointment. This requires minimum paperwork and more freedom for doctors to operate.

  1. Specialty routing

Specialty routing is a very important task for hospitals which deals with complex diseases which require the involvement of more than one specialty. With specialty routing all the doctors working on a patient can go through their medical history and reports without any manual paperwork using practice management software.

  1. Advanced tracking

The physician should be able to track all the claims submitted and the duration of the submission. The underpayments and denied claims will provide an idea to the doctor about the insurance companies’ policy. Now many insurance companies are providing doctors with online tracking facility which helps them to check the status of their claim. This also helps in planning the future endeavors of the practice.

Posted in Accounts Receivables, Claims Denials, EMR / EHR / Health IT, Health Insurance, Healthcare Reforms, ICD-10, ICD-10 Coding, Insurance / Payer, Medical Billing, Medical Billing & Coding jobs, Medical Coding, Medical Equipment, Physicians/ Doctors, Revenue Cycle Management (RCM) | Tagged , | Leave a comment

Standardize your Oncology Documentation to Maximize and Sustain Medicare Reimbursements


More than 1.6 million people are diagnosed with cancer each year in the United States. The growth in the number of people living with cancer is projected to increase from 14.5 million (2014) reaching 18.1 million in 2020. Oncology (surgical, medical and radiation) is that branch of medicine that deals with diagnosis and treatment of cancer. Due to the high figures of cancer diagnosis it becomes even more important and crucial for oncology practices to have an up to-date and standardized medical system so that all claims are reimbursed in time and that no inconvenience is caused to the patients who are facing life threatening diseases. It also contributes directly to revenue targets for a medical practice. Increased reimbursement equals increased revenues. Moreover, practices spend significant efforts in reworking claims denials to the tune of $15,000 every year in addition to millions of dollars not being paid due to faulty reimbursement processes.

So what does it take to standardize documentation process, especially with respect to the Oncology specialty?

It needs to be remembered that every step in the process of the oncology practice, needs to be documented either on pre- formatted forms or captured digitally for smooth functioning.

  1. Scheduling of Patient appointment: Here every visit including the first visit needs to be documented to capture the diagnosis and treatment to be accorded for the right codes to be billed.
  2. Eligibility and Verification: This is the most crucial part of the first phase- right from the name of the patient to the insurance coverage and what has been covered or not. Patient has to be guided, given that not everyone expects to be diagnosed with cancer and its only after diagnosis does this get established and processed for treatment.
  3. Coding: stringent coding needs to be followed. All notes by the physician need to be reviewed thoroughly and checked when codes are inserted. Laterality should be observed when taking notes or if and when recorded. If transcriptionists are being involved in the process of documentation then every word needs to be transcribed carefully noted when it comes to laterality- anatomy of the body should be thoroughly known when documenting diagnosis and treatment. Coding classifications is very crucial as it informs about the coder if the primary site has been removed or eradicated and whether that site is currently being treated- the distinction between the primary site of malignancy and any secondary (metastatic) sites
  4. Administrative Documentation: This is very crucial for the claims process. Right from first time visit through tests, surgery, treatments, claims processing and follow-ups, all these phases involve numerous documentations. Following industry standards of documentation is essential not only in medical billing and coding, it also a significant factor to reducing claims denials and having a healthy audit outcomes for the growth of the practice or organization. With the healthcare transformation in the recent past from a fee-for-service to a fee-for-value system model, it is essential to follow the best practices in documentation.
  5. Clinical Documentation is not just for administrative purposes but clinical documentation is very critical- descriptive and accurate diagnosis along with acuity and severity is essential; linkage and relationship between causal factor is a must; supporting documentation from other specialty is very necessary in certain cases; specifying what was present on admission and what has been ruled out has to be documented with clarity; clarity should be provided when a patient is admitted only for chemotherapy or radiation therapy, since these have unique admission codes and the malignancy is not considered the principal diagnosis.

For effective documentation, a medical care practice/organization should use

  1. An efficient electronic health record (EHR) system that is comprehensive enough to include charting, ordering, drug management, recording plan of care, nursing documentation, prescription management, etc.
  2. Practice Management: All workflows and processes should be automated and centralized for easy checking and auditing purposes
  3. Outsourcing core processes: You also benefit from consulting an expert medical biller and coder as they provide comprehensive solutions and crucial services like eligibility and benefit verification, preauthorization, electronic and paper claims submission, accounts receivable maintenance, insurance Billing, Insurance follow up, appeal management, denials review and re-processing. They ensure usage of the latest billing codes (ICD-10) and modifiers published by CMS(Centers for Medicare and Medicaid Services) to the highest level of specificity so that there are minimal claims’ denials and drive a sustainable reimbursement process.
  4. Follow-up Teams: this is essential even if some core processes are outsourced. To ensure the A/R collections are meeting the correct number of days, ensure that claims denied are being appealed and followed up with the right documentation as proofs, as these serve not only for claims denials but even for audits and reports as per the new rules & regulations

Oncology documentation should always ensure that the “medical necessity” is recorded in the EHR as it is one of the common reasons for denials especially given that different payers have different reimbursements coverage. Automation can streamline the overall and detailed documentation process. Standardized billing systems incorporate all the latest codes, modifiers and insurance policies into their systems so that practices do not have to spend efforts in tracking all codes and policies every time.

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