Billing Command Center

Purpose

Standardize front-desk, clinical, laboratory, provider-documentation, and billing workflows to reduce billing delays and claim issues.

Core expectations

• Verify insurance eligibility before every scheduled appointment.
• Scan the front and back of the insurance card and the patient’s photo ID.
• Confirm the correct payer / claims address and use the actual insurance company or plan name in RXNT.
• Use standardized laboratory, screening, Medicare, POC, vaccine, and documentation workflows.
• Communicate billing concerns through the appropriate manager or designated billing support channel.

Laboratory standards

• Quest Diagnostics remains the primary laboratory for applicable testing.
• Labcorp may be utilized for insurance plans that Quest does not accept as the account becomes available.
• Use approved practice-level lab macros / order sets whenever applicable to standardize ordering by visit type and complexity.

Results & patient follow-up

• Providers review laboratory results.
• After provider review, the MA contacts the patient when appropriate.
• Normal results may be communicated by the MA after provider review.
• Patients also have access to results through the RXNT patient portal.
• Patients must be notified of results within 24–48 hours.
• If abnormal results will be discussed at an already scheduled follow-up, notify the patient that the provider reviewed the results and will discuss them in greater detail at that visit.
• If the provider determines an earlier or in-person discussion is necessary, schedule appropriately.

Standard frequency

• Do not automatically complete PHQ-9 and GAD-7 at every visit.
• Generally complete these screenings once per year per patient when appropriate, unless clinically indicated or the provider instructs otherwise.

Mental health concerns

• If the patient is being seen specifically for a mental health concern, screening may be performed at an established-patient visit when appropriate.
• Screenings should be associated with the appropriate diagnosis code when billed.
• Documentation and diagnosis coding must support the service.

New Medicare patients

• Determine whether the patient is newly enrolled in Medicare.
• When applicable, determine whether a Welcome to Medicare preventive visit is appropriate.

Applicable Medicare visit components may include

• Advance Directives.
• PHQ-9.
• Vision screening.
• Patient education.
• Other required Medicare preventive services.

Documentation

• Use the Medicare note template whenever applicable.
• Ensure all required components are completed and documented.
• For G0438 / G0439 coding guidance, also review the Medicare Annual Wellness Visits card in the Coding category.

Billing & coding

• Attach the appropriate diagnosis code to the POC test.
• The diagnosis must support the reason the test was performed.

Provider documentation should support

• Why the test was performed.
• Relevant patient symptoms or complaints.
• The test performed.
• Results, when applicable.
• Clinical interpretation and/or plan.
• POC testing should be documented thoroughly in both the HPI and Plan.

Flu vaccinations

• TNC will participate in flu-vaccine distribution.
• Flu vaccine supply will be provided free by the state.
• Other vaccines may be introduced at a later date.

Injection billing

• When applicable, charge for the medication / product.
• Also charge for the injection administration.
• Ensure appropriate codes are entered for both components.

Avoid

• “Review all”
• “Negative”
• Other overly generalized ROS statements

Best practice

Document relevant systems in sufficient detail based on the patient’s presentation so the medical record supports medical necessity and appropriate billing.

Example

• Constitutional: Denies fever, chills, or unexplained weight loss.
• Respiratory: Denies cough or shortness of breath.
• Cardiovascular: Denies chest pain or palpitations.

Current transition

• RISE Medical Billing Services is being introduced as TNC’s new billing team.
• Implementation and workflow updates may take a couple of weeks during transition.
• During the transition, Ashtin and Cindy will continue assisting with billing questions and issues.
• Continue documenting billing concerns and communicating them with your manager so they can be addressed appropriately.

Complete before releasing the encounter

Standard flow

1. Provider completes and signs documentation.
2. Charges and diagnosis codes are reviewed.
3. The encounter is released to billing.
4. The claim passes internal and clearinghouse edits.
5. The payer accepts, rejects, pends, pays, or denies the claim.
6. Payment and contractual adjustments are posted.
7. Remaining patient responsibility is transferred appropriately.
8. Rejections and denials are corrected, appealed, or documented.

Important distinction

A rejected claim was generally not accepted into payer adjudication. A denied claim was processed and assigned a denial reason.

Verify and document

• Active coverage for the date of service.
• Patient name, member ID, group number, and date of birth.
• Copay, deductible, coinsurance, and out-of-pocket status.
• PCP assignment and referral requirements.
• Prior authorization requirements when applicable.
• Network status for the provider and location when available.
• Behavioral health carve-out or separate payer information.

Required standards

• Scan clear images of the front and back of every card.
• Enter the subscriber exactly as shown on the plan.
• Confirm the patient’s relationship to the subscriber.
• Use the correct payer entry and claims mailing address.
• Follow the naming format: Insurance Name – PO Box Number.
• Enter effective and termination dates when known.
• Confirm primary, secondary, and tertiary order.
• Create or update the correct case before scheduling or billing.

Office / outpatient code families

Select the level using the applicable E/M rules

• Confirm whether the patient is new or established under the applicable coding definition.
• For office / outpatient E/M, select the level using medical decision-making or qualifying total time when permitted.
• Do not choose a level because the note is long, templated, or contains a large number of review-of-systems elements.
• If coding by time, document total qualifying time on the date of service and ensure the work performed supports use of time-based coding.
• If coding by MDM, the record should support the problems addressed, data reviewed/analyzed, and risk of patient management.

Primary-care Medicare note

G2211 may be relevant with eligible office / outpatient E/M services when the visit reflects the practitioner’s ongoing responsibility as the continuing focal point for the patient’s care or ongoing care for a serious or complex condition. Confirm current Medicare and payer requirements before use.

Do not treat these as interchangeable

• A routine preventive medicine service is different from a Medicare Annual Wellness Visit.
• A Medicare AWV is a prevention-planning service and is not a routine head-to-toe physical.
• A problem-oriented E/M service addresses illness, injury, symptoms, medication management, chronic-condition management, or other medically necessary problems.

When a problem is also addressed

• Do not automatically add a problem-oriented E/M code just because a diagnosis appears in the chart.
• The additional E/M work must be medically necessary, significant, and separately identifiable from the preventive service or procedure.
• When payer rules permit separate reporting, review whether modifier 25 is appropriate on the E/M service.
• The documentation should clearly show the separately performed problem-oriented work.

Frequently reviewed modifiers

• 25: Significant, separately identifiable E/M service on the same day as another procedure or service when supported.
• 59: Distinct procedural service when the circumstances support bypassing an applicable edit and a more specific modifier is not appropriate.
• XE / XS / XP / XU: Medicare X modifiers that describe separate encounter, structure, practitioner, or unusual non-overlapping service circumstances.
• 91: Repeat clinical diagnostic laboratory test when repeated testing is medically necessary and the applicable rules are met.

Before adding any modifier

1. Identify the edit or billing circumstance you are trying to explain.
2. Confirm the modifier is allowed for the specific code pair and payer.
3. Verify that the medical record supports the modifier’s meaning.
4. Use the most specific modifier available when required by payer guidance.
5. Do not add a modifier solely to make a denied service pay.

Core outpatient principles

• Code to the highest level of specificity supported by the documentation and current ICD-10-CM guidance.
• Link each procedure, test, or service to the diagnosis or reason that supports medical necessity.
• Do not select a diagnosis because it is convenient for coverage or payment.
• For outpatient encounters, do not code uncertain diagnoses such as “probable,” “suspected,” or “rule out” as though they are confirmed; code the highest degree of certainty known for that encounter.
• Use signs and symptoms when appropriate if a definitive diagnosis has not been established.
• Follow any applicable code-first, use-additional-code, manifestation, laterality, encounter, and sequencing instructions.

Common services to review

• Injection administration and medication/product billing.
• Vaccines and vaccine administration.
• Nebulizer treatment.
• EKG / ECG services.
• Ear lavage / cerumen removal.
• Point-of-care testing.
• Behavioral-health screenings such as PHQ-9 and GAD-7 when clinically indicated and billable.

Before releasing the charge

• Confirm the service was actually performed and documented.
• Confirm the diagnosis supports the reason for the service.
• Confirm product, administration, units, route, dose, and other required details when applicable.
• Check whether the service is separately reportable or bundled into another service.
• Verify payer-specific coverage, frequency, modifier, CLIA, NDC, or authorization requirements when applicable.

Medicare preventive visit references

Screening reminders

• Confirm payer eligibility and frequency before billing a preventive or screening service.
• Do not assume every screening is covered at every annual or routine visit.
• Document the screening performed, result, clinical interpretation when required, and follow-up plan.
• Link the appropriate diagnosis or screening reason to the service.
• When a separately identifiable problem-oriented E/M service is also performed, review payer rules and modifier 25 requirements.

Final review checklist

When to review G2211

• The base service is an eligible office / outpatient E/M service.
• The practitioner is the continuing focal point for the patient’s needed health-care services, such as longitudinal primary care, or provides ongoing care for a single serious or complex condition.
• The documentation reflects the ongoing relationship / responsibility that creates the visit complexity.
• Confirm current Medicare rules, exclusions, and payer-specific processing before billing.

General use

Established patient office or outpatient visit typically supported by moderate medical decision-making or qualifying total time on the date of service.

Documentation should support

• The conditions evaluated and their status.
• Relevant records, tests, or data reviewed.
• Medication management or other treatment decisions.
• Risk associated with the conditions or treatment plan.
• Total time when coding based on time.

Common codes

Common documentation elements

• Health risk assessment.
• Medical and family history review.
• Current providers and suppliers.
• Measurements and cognitive assessment.
• Depression and functional screening.
• Personalized prevention plan and screening schedule.

Common coding references

Document

• Impacted cerumen and affected ear.
• Symptoms or clinical reason for removal.
• Method used: irrigation, lavage, or instrumentation.
• Who performed the procedure.
• Patient tolerance and post-procedure findings.

Common causes

• Missing or invalid modifier.
• Incorrect member or subscriber information.
• Missing rendering or referring provider data.
• Incomplete diagnosis or procedure information.
• Missing NDC, units, or authorization number.

Resolution steps

1. Review all accompanying remark codes.
2. Compare the claim to the encounter and payer requirements.
3. Correct the missing or invalid data.
4. Submit a corrected claim using the appropriate frequency type.
5. Document the action taken and follow-up date.

Review

• National Correct Coding Initiative edits.
• Whether the service is part of a global package.
• Whether the procedures were distinct and separately supported.
• Whether a modifier is clinically and documentation-supported.

Before creating or selecting a case

• Confirm active coverage and order of benefits.
• Confirm the payer and claims address.
• Review existing cases to prevent duplicates.
• Use a self-pay or approved Zero Pay case only when appropriate.
• Confirm the case is active for the date of service.

Workflow

1. Open the completed patient encounter.
2. Confirm the correct patient, provider, location, and case.
3. Review diagnosis and procedure codes.
4. Confirm each charge is linked to the supporting diagnosis.
5. Check modifiers, units, medication details, and notes.
6. Confirm the provider note is signed.
7. Release the encounter to billing.
8. Resolve any system edits instead of bypassing them.

Examples

• Duplicate encounters.
• Administrative or test encounters.
• Encounters intentionally designated as no-charge.
• Visits that did not occur.
• Other encounters approved as non-billable.

Designated Free Sports Physical Days

• Free sports physicals apply only on dates specifically designated by TNC as a free sports-physical event.
• Follow the approved Sports Physical / Zero Pay workflow for those event dates.
• These patients are not processed as new-patient visits for the free sports-physical event.
• Complete the applicable state sports-physical form, provide the required copy, and scan the completed form into the chart.
• Do not apply the free-event workflow to routine sports physicals scheduled outside a designated free event date.

Do not quote from an outdated fee list

Self-pay pricing can change. Staff should use the current approved TNC Financial & Billing Center or other designated fee schedule before quoting or collecting a self-pay amount.

Before collecting self-pay

• Confirm the service being provided and the current approved rate.
• Confirm whether the visit is routine self-pay, sliding-fee eligible, or an approved no-charge / Zero Pay event.
• Explain that outside laboratory, imaging, medication, vaccine, or specialty charges may be separate when applicable.
• Document the payment and visit type using the approved workflow.

Standards

• Post payments to the correct patient and date of service.
• Confirm whether funds are copay, self-pay, balance, or deposit.
• Do not leave credits unapplied without documented follow-up.
• Review payer processing before refunding an apparent overpayment.
• Use the approved refund workflow and authorization process.
• Document payment-plan arrangements clearly.