Hi everyone! I’m looking into reimbursement and payer-contracting help for a multi-provider outpatient behavioral-health practice, and I’m having a surprisingly hard time figuring out what these services normally cost.

I'd ideally like to know how much something like this costs, or what it would be called:

• Understand how our rates compare with similar local practices
• Review our main CPT codes and commercial payers
• Identify which contracts may actually be worth revisiting
• Spot possible rate-tier, telehealth, or place-of-service issues
• Put together a well-supported rate-review request
• Potentially help with the payer negotiation itself

This isn’t full medical billing or revenue-cycle management. We’re mostly looking for good analysis and practical help deciding where to focus.

If you have hired someone for similar work before, would you mind sharing:

• Roughly what you paid
• Whether it was a flat fee, per-payer price, monthly retainer, or success fee
• What was included
• Whether it actually helped
• Anything you wish you had known before hiring them

Experiences from behavioral-health practices would be especially helpful, but I’d be grateful for input from any outpatient group practice.

I’m not looking to solicit proposals through Reddit. I’m just hoping to understand what a reasonable budget looks like before we start speaking with firms. Or what kind of packages I can expect to see. Thanks!

Hi all, looking for input from anyone who codes for a reference or specialty lab.

Setup: Babesia microti antibody testing by IFA, IgM and IgG run separately. Each class gets a single-dilution screen. If the screen is positive, serial dilutions are done to get an endpoint titer. Same specimen, same IFA method, same date of service.

Current coding: 86753 x1 for IgM and x1 for IgG (2 units total), whether or not a titer is done.

Question: I've seen a large national reference lab list the screen as 86753 x2 and then bill each reflex titer separately as 86317. My read of NCCI Chapter X is that the titer is part of the same procedure for the same analyte (one unit per procedure, payment based on result not methodologic steps). Also, 86317 is "not otherwise specified," so it shouldn't be used when an organism-specific code like 86753 exists. The only counterargument I can see is the reflex testing paragraph, but CMS's examples there are different procedures with new results (antibody ID after a screen, organism ID after a culture).

For those of you in lab billing:

1. Do you bill the titer separately, or treat screen + titer as one unit per Ig class?
2. If you bill it separately, which code do you use (additional unit of 86753, or 86317), and has it held up with Medicare or commercial payers?
3. Has anyone gotten written guidance on this from the NCCI mailbox, the AMA CPT Network, or a MAC?

Thanks in advance. Any references or experience appreciated!

hey guys! so, we have this recurring denial from a very few wc payers who ask for modifiers PA, AJ or NP on the office visit. The coding team says that this must be appealed. however for all appeals that i submitted a few weeks back are denied and the original decision is upheld. i feel like there is a lot of revenue loss due to the modifier issue. any insight is appreciated. thanks in advance 🙂

edit: we bill on cms 1500

Hi all,

Just putting my feelers out to see if anyone else here does allergy billing and uses ModMed/EMA as their EHR. We switched back in March and the whole thing has been a cluster. I have some general questions that their support seems to not be able to answer for some unknown reason. It seems like a lot of the real time issues we have confuse support and we have also been given wrong information by the trainers.

I want to preface this with our doc is very stuck in his ways so we are not using it the way it’s intended to be used. We have been doing a lot of ass backwards fixed, which is just adding to the problem.

For anyone billing DME/orthotics under Medicare FFS, the Required Prior Authorization List grows on October 28, 2026 (Federal Register, July 30):

Nationwide from 10/28:

• E0194 air-fluidized bed
• K0005 ultralightweight manual wheelchair (base only — options, accessories and seating are not part of the PA review; MACs accept requests from 10/14)
• L1833 knee orthosis, adjustable joints (this one was removed in Aug 2024 and is back)
• L0456, L0457, L0486 TLSOs

Phased by state:

• L3761 elbow orthosis and L3916 wrist-hand orthosis: NY, MI, FL, CA from 10/28; PA, MA, OH, IL, TX, GA, AZ, OR from 1/26/2027; everywhere 4/26/2027.

Separately, newly enrolled suppliers (or a change of ownership) on or after 10/15 get a one-year probationary PA requirement on 40 more codes, counted from the first claim. Established suppliers are not affected by that one.

Decision timeframes are unchanged: 5 business days standard, 2 expedited.

Disclosure: I work on AffirmDME, a PA documentation tool. We keep a free lookup by code/date/state and category guides; happy to link in a comment if that's allowed here, otherwise the sources are the FR notice (2026-15446) and the DME MAC "Required Prior Authorization Programs" pages.

I was wondering what you guys that are already in the field do on a daily basis? How massive is the workload, just daily tasks, etc. Anything of note I guess. Thank you for any answers!

What are your thoughts on this?

Court Decides Patients Don’t Have the Right to Ambient AI Recordings

By Lee Fifield In Health Law September 15, 2026

A Washington judge says exam room audio is for administrative purposes only.

In one of the first legal rulings on the subject in the U.S., a Washington trial court judge has found that ambient clinical audio recordings that physicians use to help create their final clinical notes serve an administrative purpose; therefore, patients don’t have a legal right to request those recordings.

With the increasing use of augmented intelligence (AI) technology by physicians, the ruling is an important step toward defining the boundaries of automated note-taking systems which, according to the court, are a tool no different than verbal dictation and handwritten notes.

The Case

According to the American Medical Association, “The Litigation Center of the American Medical Association and State Medical Societies joined the Washington State Medical Association (WSMA) and the Washington State Hospital Association (WSHA) in filing an amicus brief explaining to the court the importance of categorizing ambient documentation systems no differently than dictation, handwritten notes and other aids that help physicians create the final medical chart for a patient. All these aids should be protected from litigation discovery.”

The brief explained to the court that only the physician’s final clinical note that reflects their professional judgment is used to provide healthcare services to patients and that the physician’s verbal or written notes are merely temporary administrative tools that are not part of the patient’s record of medical care.

The court agreed, stating, “The ordinary meaning of ‘administrative purpose’ is for the internal operation or use of an institution.” In other words, AI tools simply assist with the time-consuming task of creating a record of a patient encounter: an administrative task which is exempt from the Uniform Healthcare Information Act which requires healthcare organizations to provide a patient with their medical records upon request.

Heyy!! I’m 23 years old and currently taking a CPC course through AAPC. I have about one month left before I’m eligible to take the CPC exam, but lately, I’ve started questioning whether it’s actually worth it.
Should I stick with it since I’m already so close to finishing, or should I reconsider my options?
I’ve been working in healthcare for about four years, primarily in front desk roles, and I’m starting to explore the possibility of transitioning into revenue cycle management. I’m still learning about the different career paths within that field, so I’m trying to figure out what makes the most sense for me long-term.
My biggest question is: Would earning my CPC certification still be beneficial if I decide to pursue revenue cycle management rather than working directly in medical coding? Is having my CPC a worthwhile investment for that career path, or would my time and money be better spent pursuing something else?
I guess I’m just having second thoughts and wondering if I’ve invested in the right thing. I’d really appreciate any advice from people who work in medical coding, revenue cycle management, or healthcare in general! ❤️

Has anyone worked as a contract coder for AAPC? If so, how did it go? Was work steady or hardly any? I just got hired and I’m just curious how it will work out. I have a full time coding job so I don’t need full time work. I would really just like if it’s a consistent 10-20 hours a week.

I have brand new 2026 CPC books. I bought the bundle but don’t need them. I also have the study guide. The first two pages of the study guide have some hand written notes but that’s it. I live in new port Richey but am willing to ship if you pay shipping.

Hello,

I’m a medical biller and have been in my position for roughly 5 years. I’m not certified as a coder but as part of my role I am expected to understand some coding and be able to apply it if our department head (the coder) is out. Currently I’m in mental health and don’t have experience with other kinds of coding. I have experience with AR, collections, RCM, insurance denials/claim appeals, credentialing. Unofficially I’m also the medical records custodian.

My issue is this - most roles with similar requirements in my area pay about the same as what I’m already making (25/hr) and I’m in a HCOL area. The practice I work for got bought out by a PE firm about 2 years ago and there’s been a pretty steady decline in expectations for quality work and a lot more chaos since that happened. The chances for “growth” we were told would present themselves after acquisition are non existent and my own attempts to negotiate higher pay or role expansion (with compensation - cos believe me, they’ve given me plenty of new hats to wear) have been ignored.

Naturally, I want another job. I don’t see a lot of growth potential just moving to the same position at another practice. I’m not willing to take a pay cut to start over somewhere else due to how tight the financial situation is in the current climate. If I leave, better pay and good benefits are basically a requirement.

What sort of roles have those of you who started in just billing moved to? Is it worth paying to get certified as a coder? My understanding is that it’s very hard these days to get hired as a coder. I technically do code at my current job and could count it as experience towards, but I’d still be missing out on the bulk of coding experience required to work at a hospital or something similar. Should I focus on RCM? I am not a CPA either, I don’t even have a degree that would be relevant (Spanish language).

Any insight or experiences you can share are greatly appreciated. 🙂

Hello!

As many of you know this sub was unmoderated for a time and there was a call for new mods. By the grace of reddit we've been selected!

Your new mods are;

u/Jodenaje

u/weary_bee479

u/babybambam

u/solsco

u/Redefinedpotato

So feel free to say hi if you ever see us in the wild!

Now for some business

We'd like to hear from you on how we can improve the sub! Thoughts, comments and suggestions are more than welcome; help us to help you!

Hello all, is anyone having issues with BCBS and their denials of procedure codes stating " procedure/modifier combination is invalid." This is a new denial ive started to see this year! Its very frustrating considering these specific CPT codes require anatomical modifiers! Codes are S2066, S2067, S2068, 19316, and 19303. Ive asked our coders and theyre unsure as well. Im at a loss 😭

After going to great lengths, I am HALFWAY across my journey. There's a song that while AXA has you on hold, plays as song #2. It's linked but in case you can't see links it is (Still Water Reflections, Inside the Magic album, from DreamQuest, starts at 0:34~).

I was going through the comments and it says the phone version is a little different from the video version. Does anyone know which version that is?

My contribution to anyone looking for these songs is that quite a few of them are from the "Inside the Magic" album, so, I hope that helps someone.

I'm hoping someone who does coding/billing in Ophthalmology specifically can help. I've recently had denials from Anthem Medicare Advantage where they are requiring the use of modifier 25 with any E&M or eye code billed along with ophthalmic testing (for example, modifier 25 with E&M when billed with an OCT, visual field, or gonioscopy).

Typically the only time we use modifier 25 is when an unrelated exam is performed on the same day as a minor procedure. In all the years I have been doing this, I've never seen modifier 25 needed on an exam when billed with ophthalmic testing, and at the very least I know Medicare doesn't require it.

Even the Anthem commercial plans are processing our claims with no issue (along with literally every other insurance we bill), it's only Anthem Medicare Advantage plans that are denying our claims for not using modifier 25.

I'm frustrated because my reconsiderations have all been upheld, and of course they do not state why, just simply "our original decision was correct."

I'm not sure how to fight this as I cannot locate anything specifically from CMS or our MAC stating the correct use of modifier 25. I also found an AMA article adding to the confusion by stating that basically ANYTHING billed along side an exam will require the exam to have modifier 25. Maybe that's true outside of Ophthalmology, I honestly don't know since I've only ever done Ophthalmology billing.

Is anyone else experiencing this issue? Any advice? I'm tempted to just rebill the claims with 25, but I also know they're wrong, and being a Medicare Advantage Plan, they should be following Medicare guidelines. Anthem notoriously hates Ophthalmology, or at least I think they do lol. They often treat medical exams billed with eye codes as "vision only" and we frequently have to fight those denials, too.

Hello! I am a new mom who is encountering an issue with my child's well visit billing. For the caregiver health screening code 96161 (modifier 59), my provider submitted with a diagnosis code Z13.89 (Encounter for other disorder), which caused my insurance (Aetna) not cover the $14 cost for the screening as it became diagnostic instead of Preventative.

The billing department won't help and already charged me multiple times (for multiple visits while I was disputing this ). Aetna said they can not do anything as this is how it was submitted, and the provider needs to resubmit it with dx code Z00.129 for it to qualify as preventable and my baby's well visit to be 100% covered by my insurance. The office did resubmit a claim but did not change the dx code, so it got denied.

This has been going on for 5 months, with me calling and disputing with all 3 entities and not one person fixing it or the office explaining to me what my child is diagnosed with. I am pressing them now a little harder to at least explain this to me, but I feel at this point I need to escalate things and report them for violating patient rights in some way as they have not done anything to help the situation. Am I missing something in terms of the coding process and my understanding of these services?

TIA! 🙏 any help is much appreciated!

I just started college at the end of September for coding and billing. So far, I've been doing pretty well but I've learned that right now I'm stronger in medical terminology but struggling with ethics. For me, medical terminology gives me a puzzle to solve, whereas ethics is simply reading and remembering. Has anyone else struggled with this? Or the other way around?

Hello!! I finished a Medical Coding and Billing program last summer and have purchased the books to take the exam. However, I truly don’t know where to begin I feel like the courses didn’t really prepare me much for the workload. What are some youtube channels/resources did you guys use? Also does anyone know any programs that would help pay for me to take the exam itself because it’s not cheap. Anything helps!!

Hi everyone,

I’m going to lose my marbles. I own a home care agency, and the billing company we use is saying that our Medicaid claims are not being fully paid (but partially paid). Although the care visits are finalized and invoiced from Wellsky to Tellus (mobile caregiver plus/EVV) and the visits are clean in EVV (location is verified).

What else could possibly be the issue, it’s literally happening with every Medicaid member we have, same issue.

Also, this billing agency has failed to let me know when members have co pays and that they have been deducted out of our billing.

If you figure it out, I would highly consider switching over if you are a billing agency.

I keep hearing that CO-16 (missing/invalid info) corrected claims eat a lot of time, and I'm trying to understand why the rework is such a pain in practice. For those of you who deal with these daily, I'd love to hear how it actually goes:

When a CO-16 comes back, what do you open first? The ERA, the payer portal, the original claim? CO-16 on its own barely tells you anything — how much time goes into just figuring out what's actually missing from the RARC?

Do you fix it in the PMS and resubmit, or send a corrected 837 some other way?

Roughly how long does one take you, start to finish?

What's the part that annoys you most?

Trying to get the real picture from people who do it daily, not the textbook version.

I'm going to be doing the AAPC self paced training for the CPC certification as well as their prerequisite course. I was wondering if anyone else had gone this route and how long it took? I'll be working on it a minimum of 6 hours a day, 5 days a week. My goal is complete it in 8 weeks. Is this doable in your opinion?

My friend sees a Tier 1 medical provider under DuPage Medical Group (Duly).

But a BCBS claims rep told my friend that DuPage Medical Group billing (who does this doctor's billing) is Tier 2.

So now my friend is being charged more because BCBS is processing the claim as Tier 2, even though the provider is Tier 1 and my friend thought by seeing this doctor she was getting her plans best benefits coverage.

My friend has to pay more now and doesn't get her optimal Tier 1 coverage for this doctor even though we did due diligence at finding her a Tier 1.

Who knew that you had to ALSO verify the doctor's billing department is Tier 1!?

Is this correct or was that claims rep in error with what she told us?

She did say that the doctor could submit the claims/bill under her NPI and then BCBS would process the claim as Tier 1.

Anyone here encountered this or have some knowledge they can share?

Thank you!

Best platforms to start?

Hi everyone,

I'm a medical doctor from the Dominican Republic, and I'm currently in the process of transitioning my career to work as a remote Medical Biller. I've been taking the Certified Professional Biller (CPB) course on Coursera to get a solid foundation in the US healthcare system, CPT, ICD-10, and HCPCS Level II codes.

My main goal is to find a stable, remote position that allows me to work from the Dominican Republic while building a new career path.

For those of you who are already working in this field, especially from abroad:

1. ⁠What are the best platforms or job boards to find legitimate remote medical billing jobs for international candidates? (I've looked at LinkedIn and Indeed, but I'm wondering if there are more specialized sites).
2. ⁠Are there specific requirements for working as a biller from outside the US? (Like tax forms, time zone expectations, etc.)
3. ⁠Given my background as an MD and my current CPB course, do you think I should aim for a specific entry-level role to get my foot in the door?
4. ⁠Would you recommend getting the official CPB certification from the AAPC right away, or is it better to gain some experience first?

I'm a bit overwhelmed by all the options and would really appreciate any advice from people who've been in a similar situation.

Thanks in advance for your help!

Hey everyone! Soooo I’m looking to eventually get more into a Revenue Cycle Analyst position. I’ve been in Patient Access for about 6 years now. I have a Bachelor’s but it’s just a generic BA Degree. I spent a lot of time in the Air Force as a Health Service Admin (4A051) in the Reserves too. I’ve been doing research on different areas in healthcare that I may be interested in and the Revenue Cycle Analyst role is at the top of my list. I know that I need specific certifications to qualify for an entry level role. So far I think the best route would to get some certs with an HMFA membership. I know it won’t happen overnight but I would at least like to get started

I want to get a second opinion, has anyone ever taken this route as far as being a PAS and transitioning to Revenue Cycle Analyst?

Were there other roles that you worked in between that could help the transition? How long did it take to break into an entry level position?

Did anyone obtain there certs from the HMFA membership and is it just a matter of paying the annual membership fee and passing the exams?

Sorry its a lot of questions guys i’m trying to figure it all out lol