With so many challenges to face daily, it has become more and more difficult for practices to free time to focus on what is most important; the patient. Thankfully, medical billing software has given practices worldwide the tools they need to take the challenge out of office management. Offering numerous features and capabilities, medical billing software has helped medical practices manage revenue, productivity, and allows the patient to again become the focus.

Over the years, medical billing software has been continually adjusted to meet the needs of an ever-changing health care profession. Medical billing software has helped practices worldwide to save substantial money by lessening expenses and run at peak efficiency. Time means money for most businesses. The right software can handle time consuming tasks, and free up the needed time to focus on improving patient care and reaching your practice goals. Many offer the flexibility to customize to meet your exact office needs, and allow office staff to work on separate tasks simultaneously.

Some people believe medical billing software has to be expensive to be quality, but this isn't necessarily true. There are a variety of affordable options offering advanced features perfect for any budget. Taking the time to evaluate your office needs can help you to narrow down the search. You can also save a lot of time by first getting an accurate idea of which features would best benefit your practice. You can see firsthand if the software will work for you by participating in free demos or free trials. It is very important that the company you choose offers excellent customer support.

Be sure to involve your staff in your software decision, as the medical billing software you choose will affect all members of your practice differently. Whether a nurse, receptionist, physician or office manager; each has unique needs to be addressed. Listen to all the concerns or ideas you staff have now and save frustration and problems in the future.

Save substantial time on insurance billing with medical billing software. Most software will allow you to bill electronically to the insurance companies, saving considerable time and stress. No more sending and resending claims which wastes precious time; many notify you of errors before the claim is even sent. You will also receive payment faster as well.


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Medical billing and coding are vital parts of the billing process. From the time a doctor sees a patient to when the paperwork is forwarded to the insurance company, there are important steps that need to be performed. Every doctor visit results in the utilization of medical coding and medical billing skills - both are necessary for doctors and health care facilities to be properly reimbursed for services.

Here's how it works:

Medical coding includes the process of using specific codes to identify procedures and services for private billing, health insurance companies, government health programs, workers' compensation carriers, and more. A coder reads all documentation, such as a medical chart or transcription of doctor's notes, and assigns the right universal code based on their coding knowledge. The codes are entered into a form on their computer system.

Medical codes are based on diagnoses and procedures. Codes exist for all types of services, tests and treatments provided by a healthcare provider in a medical office, hospital, or clinic. The diagnosis is translated into an ICD-9-CM code; while the procedure is translated into a five-digit CPT code. Medical codes can encompass anything from a stomach ache to a broken arm - there are codes for everything!

Once the diagnosis and procedure codes are determined, the medical biller transmits the claim to the insurance company for payment. Medical billing includes the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a health care provider. A billing specialist ensures that the patient and health insurance company are properly billed for all procedures. Approved claims are reimbursed, while rejected claims are researched and amended.

Under the Health Insurance Portability and Accountability Act (HIPAA), billing specialists are required to send claims for reimbursement via electronic means. This has resulted in faster, more accurate payments from insurance companies. The use of billing software has also enabled medical billers to perform accounting duties and manage billing practices more effectively. Patient records, open claims and outstanding invoices are a mouse click away!

Medical billers and medical coders ensure that the billing cycle is smooth - from patients being billed the correct amount to doctors getting paid. Without them, there would be no way to complete, track and manage medical claims. Both billers and coders are essential to the financial well-being of an organization and the health care industry as a whole.



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Insurance bundling is the process where a payer will often lump separate charges together to pay your practice less.

For example, lets say you have a patient that comes in for evaluation of high blood pressure and you notice the patient has two suspicious skin lesions - one on their left arm and one on their stomach. You then make the determination to excise one and perform a biopsy on the other.

You code 99214 with modifier -25 (E&M for patient with high blood pressure); 11403 (stomach lesion excision, benign, 3.0 cm); 11100 with modifier -59 (biopsy of arm lesion).

Modifier -25 is to be appended to a CPT code that is a separate and distinct service that is provided during the same visit. If modifier -25 is not added to the evaluation and management code (99214) both lesion codes could be denied, or the 99214 code itself might be denied. Modifier -25 identifies to the payer that the codes are truly separate services that were rendered.

Modifier -59 is to be utilized for a distinct procedural service and alerts the payer that two services that usually would be bundled into the lesion code should be reimbursed separately because the biopsy (11100) was performed separately. The two lesions that were examined were definitely separate, distinct and unrelated to each other.

If the insurance company does not pay for each service and is ignoring the modifiers -25 and -59, ultimately they are bundling.

The best way to fight back against bundling is to track your claims submissions and check them against your explanation of benefits forms to ensure that all services are paid.

The following are indicators your payers may be bundling your services:

* An E&M code is indicated but no payment was made because the carrier bundled the charge with that of an unrelated service.
* When the charge is listed but no payment was made because the payer bundled the charge with an unrelated charge for another diagnosis. When this occurs you will often see the following denial code, "Payment for this service is included in the fee for the procedure."
* When the modifier is listed but the payer omits the service modifier (such as the -25 or -59) and no payment is made.
* When the code is totally omitted from the EOB as though the service was never rendered. For instance, you coded an E&M code and a minor outpatient surgery on the same day. The claim was filed using the -25 modifier. When the EOB's are received, the only charge noted is the surgery code. The E&M code is not included.

Certain explanations on your EOB's may also indicate that the payer is bundling some of your charges. Examples are as follows:

* Medical visit not allowed for separate reimbursement
* The procedure code submitted on your claim has been changed to one that better represents the services performed by your physician.
* Payment for one or more billed procedure codes has been denied because it is considered a component of this billed procedure code.
* Payment for this service is included in the fee for the procedure.
* This service is a component of a primary procedure. Payment for the primary procedure includes reimbursement for the related procedure.

Make sure and analyze your EOB's for an extended period of time to identify if any of the issues above exist in your practice. Make a list of the payers that are attempting to bundle and what CPT codes and procedures they are bundling so your staff will be aware of this and keep an eye out for it moving forward.

Once you identify any charges that are being bundled, go ahead and immediately appeal those with the payer. It's imperative that you address it immediately as each payer has a deadline in terms of when a claim can be appealed.

The bottom line is to not accept what the insurance company pays but to ensure that payment has been made in accordance with your contract and that no bundling is occurring.

Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, and other general medical practice consulting services.


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