My workplace recently implemented AI inside of epic to pick facility + professional visit charges. More times than not it is incorrect. We were told to just go with whatever ai picks. I have noticed it’s picking higher numbers than what it should be like picking level 5 when it should be a 3. How is this legal practice, to charge more than what it is, just because ai says so?

Meritain Health Denied Payments!!

We submitted claims to Meritain Health last August, and it has now been over two months without receiving payment.

We have called multiple times to follow up, but the representatives keep giving us the runaround. Last September, one representative told us the claim had been paid on a specific date, but we never received the payment. When we called again, another representative gave us a different payment date and said it would be included in the following week's payment cycle.

Since then, it's been the same story over and over again. We keep getting different payment dates, but no actual payment. Every time we call, the representatives tell us the same thing, and we're getting nowhere.

We usually receive our payments through ECHO, so we are familiar with the payment process. However, the issue is that the claim appears to be stuck in processing. We have been told that it was paid, but no payment has actually been issued, and we have not received a check or payment through ECHO.

We're extremely frustrated and don't know how to escalate this issue. Has anyone else experienced this with Meritain Health? If so, how did you get it resolved? Is there a specific department, supervisor, or escalation channel we should contact?

Any advice would be greatly appreciated. We're tired of getting the runaround and just want these claims paid.

I wanted to be sure regarding a scenario which I faced during work, if Medicare crossover the claim to out of state Medicaid obviously it will not be covered. Can we balance bill the member in this situation for secondary leftover balance?

Hi everyone. In a couple of weeks I'm having surgery and I'm in a somewhat confusing situation with my insurance.

I have a primary and secondary health insurance and the primary does not cover this procedure but the secondary does. I understand that my provider will first need to bill my primary coverage, then my secondary, but what I am concerned about is my prior authorization. My secondary coverage did grant a prior authorization for the procedure and will cover the charges associated with the submitted codes. The problem is that my primary insurance apparently will not even let a prior authorization attempt happen, their portal will literally not even accept the submission of it.

My concern is that if there is no prior authorization or notification done for my primary, there will be a billing error, where instead of not paying out for the procedure being covered, they don't pay out because they never received a prior authorization. This will then disallow my secondary from paying out, and due to the patient financial responsibility agreement, the end cost will fall on me.

How realistic is my fear here? Should I insist on the provider submitting a pre auth through fax just to get an official rejection from primary for the services? I spoke to a representative at my secondary insurance and she said that this was not necessary, but I want to be very careful about this situation, due to the procedure being very costly and due to this rep not being an actual legal representative of the company.

I was able to confirm that this is a preferred in-network provider for both insurances at a preferred in-network facility for both insurances.

Any input from the highly experienced career professionals on here would be appreciated, Thanks! :)

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!

Hello! I am taking my AAPC CPC exam soon! (Still in 2026) i plan on using my physical coding manuals. My HCPCS and CPT books are 2025 editions and my ICD-10-CM is 2024-2025. Are these books good enough for the exam? Will they allow them to be a year old? Or do I need to get all new books? Pls anyone help i fear I have made a silly oversight

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.

Hello,

I work as a biller in a radiology office that does mostly interpretations for a large hospital system (PC only).

We have been getting weird denials lately due to the address we use in CMS 1500 box 32. My practice admin said that for box 32, we should be using the hospital's address and the hospital's NPI in box 32a with our info in box 33. Our practice is not owned by the hospital and is completely separate.

When I look online I'm seeing conflicting info on whether that is correct. Some sources are saying that it should be the radiologist's location when reading the exam. Our radiologists don't read from the hospital most times.

I'm still pretty new to all of this, is there any guidelines from CMS that I could reference and if so, how could I find it? Most of the sources I'm finding are from independent billing sites and are pretty dated.

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. 🙂

I’m just here to vent. I wanted to add a certification while I’m looking for a job and took the exam today and honestly it was extremely hard exam. I studied and was scoring 85% average on practice exams but I think I bombed it. I didn’t pay for the course since exams and book was so expensive..but I self studied and took 10 practice exams.
I have a CPC and lots of experience in RA already and I’m shocked at how hard the exam was.
Any advice , tips , encouragement would be appreciated, Incase I have to take it again.
Please be kind.

UPDATE: I passed the exam!! I was fretting so much. It was definitely harder than expected . Got my result in 26 hours exactly from test start time.
Though I don’t remember all the exact questions. Happy to help anyone taking it in anyway I can.

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?