Using nickname “Mike” vs legal “Michael”.
Using married name vs maiden name on insurance card.
DOB off by 1 digit.
Always verify against active insurance card, not driver’s license or EHR history.
Run eligibility the day before DOS and screenshot it.
Pro Tip: Create an intake rule: “No insurance card image = No appointment.”
Verify via Availity / payer portal / 270/271.
Document reference number + agent name.
If Medicaid, check eligibility on DOS. It changes daily.
Red Flag: If patient says “I think I have Blue Cross”. Stop and verify. “I think” = denial.
Auth for 99213 but you billed 99214.
Auth for 6 visits, you billed 7th.
Auth for Dr. A, but Dr. B saw patient.
Put Auth no in Box 23.
Attach auth letter on first submission if payer requires it.
Track expiry dates in a sheet.
Never bill before auth is in writing.
Script: “This procedure requires auth from------- We have auth # [XXXX] valid until for [CPT].”[Payer][Date]
Maintain a matrix:
Before first claim for new provider, check matrix, not memory.
Tool: CAQH + PECOS + NPPES must all match i.e. Name, Address, Taxonomy.
Must be a real, active, enrolled NPI that is required for
Referring provider retired, deceased, or not enrolled in Medicare. Or leaving 17b blank.
M54.5 (Low back pain) to justify MRI Lumbar. Payer wants M51.37 (Intervertebral disc degeneration, lumbosacral). Or using Z00.6 (Encounter for general exam) with sick visit.
Rule: If payer LCD says “CPT X requires Dx Y or Z”, print that LCD and give to provider.
Run every claim through an NCCI checker before submission.
Modifier 25 = “Significant, separately identifiable E/M on same day as procedure.”
Document must prove it.
Pro Tip: Modifier 59 is last resort. Use XS, XP, XU, XE when possible.
POS 11 for hospital owned clinic that should be POS 19/22 = payment difference of $30-$70. Or DOS after patient death/discharge.
Why this matters: If blank, Medicare and many Blue plans says that claim legally must pay by the PATIENT. You then have to collect from patient, not payer. And collection rate on that = <15%.
EHR on default leaves it blank . Or biller thinks “we don’t accept assignment for this plan.”
Box 13 = Y authorizes payer to pay you, not patient.
Box 12 = consent to release info.
Math: If your average claim = $150 and you miss timely on 10/month = $18,000/year written off.
Does payer require: Operative note, Office note, Lab report, ABN for Medicare, LMN, Invoice for DME, W9 for new location?
If yes, send WITH claim, not after denial.
Billing 99214 with modifier 25 but not sending office note. Or high level E/M without documentation to support it.
Build payer specific rules sheet:
ABN Note: For Medicare, if you think service may be non covered, get ABN signed BEFORE service, add modifier GA, attach ABN.
BONUS: Pre submission 30 Seconds Audit
Before you hit SEND, ask 3 questions:
If NO to any , FIX IT NOW.
(Disclaimer: This checklist is for educational purposes only and does not constitute legal, coding, or compliance advice. CPT® is a registered trademark of the AMA. ICD-10 guidelines change annually. Always verify with current payer policies, NCCI edits, and your compliance officer. No PHI was used to create this document.)
