Running an Effective Medical Practice

Most medical practices are hectic, and the physicians must be freed up to spend as much time as possible in helping patients through research and direct care. The most effective offices operate as a team, with each member being well qualified in their role. This kind of synergy does not happen by accident. Here are three qualities of a medical office team that works together for the benefit of its patients.

Understand what the goals are

It seems logical that the purpose of a medical office is to serve the patients, and the hope is that’s the case. But, there are times when the ultimate goal ends up being to help the doctor since they are “the boss.” If the doctor’s agendas make patient goals impossible to achieve, there is a problem. Therefore, the next steps should be a plan to get everyone on the team on the same page, and that is understanding that the office works for the patient, and the team is required to satisfy the patient’s needs.

Clarify everyone’s role

A key to running an effective practice is everyone knowing what their role and duties are. For example, a patient might need a blood pressure recheck while in the office, but the intake nurse gets busy, and no one remembers to do it. In cases like these, if someone is assigned to cover certain tasks throughout the day, then specific aspects of patient care are not missed. Cross-training is essential, but clearly defining these roles proves to be a service to the patients and the practice.

Communication is key

As with most systems and groups, good communication is at the heart of happy customers—and in this case, happy patients. Communication runs in all directions, from among those on the team to the patients to other practices. There are many platforms that today’s practices use to be efficient in communication. One example is when patients notify the office of a pressing concern. They likely only tell one member of the medical team, whether the scheduler, nurse, or physician. If there is not a sound system in place, the result could be an unhappy patient experience, leading to bad reviews via the web or, even worse, the death of a patient.

Bottom Line

When practices are chaotic, it is difficult to motivate staff members to make changes to better the team because everyone is just trying to keep up. However, being willing to evolve and improve constantly is one of the best guarantees for a successful practice. Arrange some goal-setting sessions and distribute communication about what roles people fill and how important those roles are to the team. The culture comes from the top down, and if the physicians are enthusiastic about these crucial points, so will the team members.

Modifiers: What are they, and why do we care about them?

Modifiers are among the essential tools medical billers and administrators have in their arsenal. They can clarify complicated procedures, indicate special circumstances, and more. This post will explain what modifiers are and how billers should use them. Stay tuned for future posts that will dive into more specific applications of modifiers!

What are modifiers and how are they be used?

A medical coding modifier is an appendix to a CPT® or HCPCS Level II code. A modifier typically consists of two characters (letters or numbers). The purpose of the modifier is to provide additional details about the services or supplies performed at the place of service without changing the meaning of the code. For example, a biller should use a modifier to indicate which side of the body the procedure was done when billing for orthopedic surgery. Modifiers are also critical in reporting if the procedure was performed twice to a specific part of the body or performed to a particular part of the body. The appropriate modifier will determine how the claim is processed and prevent the payer from denying the claim as a duplicate or bundled procedure. This blog will explore the most commonly used modifiers in medical billing and offer some examples of using them.

The Common Modifiers

24 Unrelated Evaluation and Management Services by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period

25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Source–(The most used modifier in medical billing) Use this modifier if other services were performed not related to E/M.

26 Professional Component–Used to indicate that the service provided was the interpretation of results with a written report of the interpretation of a technical component (laboratory and/or diagnostic service.

50 Bilateral procedure–(Commonly used in orthopedic surgery)
Before utilizing this modifier, the biller must familiarize themselves with the preference of RT or LT instead of the 50 modifiers.

51 Multiple Procedures–Used when multiple procedures, other than E/M services, or provision of supplies are performed at the same session by the same provider**PROCEDURES SHOULD BE DIFFERENT

52 Reduced Services–Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s or other qualified healthcare professional’s discretion. Under these circumstances, the service provided can be identified by its usual procedure code and the addition of modifier 52.

54 Surgical care only

57 Decision for surgery

59 Distinct procedural service–Used to indicate a service should not be considered a bundled service when it normally might be bundled.

78 Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professionals following initial procedure for a related procedure during the postoperative period (complication).

79 Unrelated procedure or service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

95/GT Synchronous Telemedicine Service Rendered Via a Realtime Interactive Audio and Video Telecommunications System

GQ Via asynchronous telecommunications system

Some examples of correct use of modifiers

(Out-patient and office visits)

Example #1:

Using Modifier 51

A 79-year-old male has acute cholecystitis and abnormal liver function test. He has elected to go for surgery. A laparoscopy is placed through an epigastric incision with the insertion of two lateral 5mm ports. The gallbladder is elevated, and the cystic duct is located and dissected out. In the process of transecting the duct, the gall bladder tears and several gallstones were released. These are removed with a gallstone retriever along with removal of the gallbladder. The cystic duct stump is tied off and the common bile duct is incised. A large stone is seen and removed. The common bile duct is closed over a T-tube catheter which is brought out through the abdominal wall and connected to a drainage bag. What CPT® code(s) should be reported for this procedure?

A. 47564

B. 47480, 47564-51

C. 47420, 47562-51

D. 47480, 47562-51

Example #2:

Using Modifier 59

Operative Note #1:

Procedures Performed: Excision with layered closure right lower leg; Excision of a melanoma in situ on left dorsal forearm.

Preoperative Diagnosis: Basal cell carcinoma right lower leg and Melanoma in situ, left dorsal forearm.

Postoperative Diagnosis: Basal cell carcinoma right lower leg and Melanoma in situ, left dorsal forearm.

Indications: Well-marginated, erythematous, slightly scaly, plaque(s): posterior right lower leg.

Biopsy revealed a superficial BCC (basal cell carcinoma). The patient is allergic to Codeine. The patient takes the following medication(s): Hydroxyurea, alegralide, Boniva. Informed consent was obtained from the patient. Risks of the procedure including, bleeding, infection, scarring, and recurrence were explained, and the patient acknowledged understanding of these potential complications.

Procedure: The preoperative measurement of the lesion on the right lower leg was 0.9 cm. The proposed excision lines were drawn. Anesthesia was delivered locally with 12.0 cc of 1% Xylocaine with epinephrine buffered 1:10. The site was cleansed with Betadine. The site was prepped and draped in the usual sterile fashion. An incision was performed with a number 15 blade 0.5 cm outside the margin of the identified neoplasm extending deep, through the dermis, and into the subcutaneous fat. The excised diameter (total preoperative dimensions including margins) measured 1.9 cm. The specimen was tagged at the superior tip. This tissue was dissected from the patient with care to preserve histologic features. The surgical site was undermined to a distance of 2.0 cm. Hemostasis was obtained by electrocautery and vessels ligated as necessary. The specimen was placed in a bottle of Formalin labeled with the patient’s identifying information. The specimen was sent for pathologic and margin analysis. In order to prevent dehiscence due to wound tension, an intermediate layered closure was performed. Seven 4-0 Polysorbtm sutures were placed subcuticularly utilizing a simple inverted interrupted stitch. Seven 4-0 nylon sutures were placed cutaneously utilizing a simple interrupted stitch. The final length of the surgical repair was 2.5 cm. The surgical site was cleansed with saline. A sterile dressing was applied utilizing the following: sterile petrolatum, gauze, and taped into place to form a pressure bandage. The patient tolerated the procedure well. Postoperative instructions were given to the patient. The patient was instructed to return in nine days for suture removal.

Lesion Treatment: The lesion on the left dorsal forearm was cleansed with alcohol and anesthetized with lidocaine with epinephrine. Electrodesiccated and curetted x 3. Appropriate dressing was applied, and post-op instructions were given. The final defect measures 0.9 cm in size.

The patient tolerated both procedures well. Recommended routine skin examination in three months. The patient was released in good condition.

What are the CPT® and ICD-10-CM codes for this procedure?

Wheeww! Now a simpler example of 59 modifier in use!

Example #3:

Using Modifier 59 Pt. II

A 5-year-old female presents to the doctor’s office with a sore throat, fever, and fatigue. A Streptococcus, Group A, and Influenza A and B tests are performed in the office.

What CPT® code(s) should be reported for this procedure?

A. 87650,87804,87804

B. 87880, 87804-50


D. 87880,87804,87804-59

**Please scroll to the bottom for correct answers with rationale**

Answers with rationale

Example 1: C

Rationale: In the CPT® Index, look for Bile Duct/Removal/Calculi (Stone). Review the codes to choose the appropriate service. Code 47420 is correct. A choledochotomy (incision of the bile duct) was done for removing a stone, and a choledochostomy ( a stoma was made in the abdominal wall from the bile duct for drainage) was done. In the CPT® Index, look for Gallbladder/Excision- See Cholecystectomy. Look for Cholecystectomy/Laparoscopic referring you to codes 47562-47564. Review the codes to choose the appropriate service. Code 47562 is correct. There was a removal of the gallbladder through a laparoscope without cholangiography.

Example 2: 11602-59, 12031-59, 17261, C44.712, D03.62

Rationale: The first lesion is basal cell carcinoma right lower leg and is excised with a layered closure. Basal cell carcinoma is a malignant lesion, so you will begin by looking in the CPT® codebook at the range for excision of malignant lesion (11600-11646) (Excision /Lesion/Skin/Malignant). The range is narrowed by the location of the excision–right lower leg (1160-11606). The size of the lesion is determined by the excised diameter which is 1.9 cm, further defining the code to be 11602. This was closed with an intermediate layered closure. When an excision is closed with an intermediate closure, the closure can be coded separately. The wound is 2.5 cm in length and reported with 12031. The diagnosis is for a basal cell carcinoma of the right lower leg.

The second lesion is Melanoma in situ, left dorsal forearm. The lesion is treated using electrodissection indicating it was destroyed. To find the CPT® code, look in the CPT® Index for Destruction/Lesion/Skin/Malignant. Code range 17260-17286 is for destruction, malignant lesion, any method. Code range 17260-17266 is further narrowed to lesions of the trunk, arms, or legs. The lesion measures .9 cm, so CPT® code 17261 is appropriate. The diagnosis is for malignant neoplasm of the arm. Code 17000 is for destruction of premalignant lesions.

Modifier 59 is appended to 11602 and 12031, indicating it was performed on a different site than 17261. Code 11602 and 17261 are mutually exclusive according to NCCI edits, but a modifier is allowed to report the services. The codes are listed in RVU order. Modifier 59 can be reported on a primary CPT® code because in this case, code 11602 is in column 2 on the NCCI table when reported with code 17261. Modifier 59 is reported on codes in column 2 listed in the NCCI Table. **You will not be tested on listing codes in RVU order or reporting modifier 59 for NCCI edits on the CPC exam.**

To find the first diagnosis code, look at the Table of Neoplasms in the ICD-10-CM codebook. Look for skin NOS/limb NEC/lower basal cell carcinoma and use the code from the Malignant Primary column C44.71-. In the Tabular List, C44.712 is reported for basal cell carcinoma of the skin of the right lower limb. In the ICD-10-CM Alphabetic Index, look for Melanoma/in situ/forearm referring you to D03.6-. In the Tabular List, D03.6 requires a 5th character to indicate laterality. Code D03.62 is for Melanoma in situ of the left upper limb.

Example #3: D

Rationale: In the CPT® Index, look for Streptococcus, Group A. Since there is no mention of whether it was for Antigen Detection, you would look at the next category: Direct Optical Observation, 87880. When you look at the code with description, it clearly states, Streptococcus, group A. The code 87880 is correct.

The other procedure performed was Influenza A and B. In the CPT® Index, look for Influenza Virus/Detection/With Direct Optical Observation. You would not look under Influenza A or B in the index, as it does not state there was Antigen Detection performed. The correct answer is 87804.

You would report the code, 87804 twice since Influenza A and B were performed, then append the 59 modifier on the second code to indicate as a separate procedure from the first code.

That’s all folks!

That’s it for our discussion of modifiers! We know they can be confusing, but they are essential to understand to get paid correctly for the services you provide. If you have any questions or need further clarification on a specific modifier, please leave us a comment below, and we will do our best to help out. In the meantime, keep an eye out for future blog posts that will go into more detail about specific CPT® codes and how to bill them accurately. And as always, happy coding!


American Medical Association. (2020). CPC Certification 2021. Salt Lake City: AAPC.

American Medical Association. (2021). CPT 2021 Professional Edition. AMA.

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3 Reasons Why Medical Providers Should Bill Specimen Handling Code

What is specimen handling?

Specimen handling involves collecting, preserving, and transporting specimens (such as blood or urine) sufficiently and stably to provide accurate and precise results suitable for clinical interpretation.

1 Specimen Handling is essential for patient care

When a patient presents with an ailment, the physician’s role is to order the appropriate laboratory tests that play a pivotal role in the final diagnosis of the disease and its management. The maximum accuracy of these diagnostic results begins with the accuracy of the staff handling the specimen. The back-office staff operating the samples should know and follow proper sterile techniques and guidelines for carefully collecting and disposing contaminated specimens and other biological material.

Except for certain medical facilities and practices, this is a necessity if they do not have the medical equipment required to perform clinical interpretation. The most common tests often requiring an outside laboratory to process are: 

  • Throat cultures
  • Mono spots
  • Urinalyses
  • STD panels
  • Obesity panels
  • Blood typing
  • PCR

While some practices have invested in the equipment they feel necessary for their practice; many others find it more advantageous to outsource this workflow to free up their resources.

2 You can get paid up to 60% of your fee

Some insurance companies reimburse up to sixty percent of the amount billed, but this depends on each contract between insurance companies, the diagnosis code, and other variables such as the patient’s out-of-pocket expenses, deductible, or co-pays. A majority of insurance companies deny the procedure as inclusive with no patient responsibility. However, all is not lost. Physicians can and should profit from this service which takes up staff time and resources. Here’s how:

  • Create a set fee for specimen handling
  • Keep track of the schedule that your nursing staff sees as lab visits only.
  • Have a waiver ready for the patient to sign. The waiver must state clearly why the patient signature is needed and must include the CPT code and fee.
  • Collect payment upfront 
  • Run reports often to track revenue for this service

*Please note that Medicare and Medicaid patients are excluded from the above. Check CMS guidelines for further information.*

3 Specimen handling in-office decreases anxiety of going to an outside lab

When patients visit their physicians for a suspected illness, they often already have reservations and fears of what their condition may be. They hesitate in just scheduling the visit. If a patient enters your office with anxiety, they can be irritable or have difficulty remembering instructions given to them for treatment. Furthermore, as providers of care, an environment must be created to reduce these symptoms.

 One of the tactics in reducing anxiety symptoms is making things as convenient for the patient as possible. If the need to visit an outside laboratory is one of the factors in your patient’s anxiousness, you can quickly eliminate that factor by collecting the specimen in your office.

What is the CPT code for specimen handling?

The CPT code for specimen handling is 99000. Depending on the specimen collected, the code can be billed to insurance alone if the patient did not see the doctor during the visit. Otherwise, make sure your billing staff bills out HOW the specimen was collected (e.g., Via venipuncture or fingerstick), as payment should be expected on those services as well.

Which insurance companies pay for specimen handling?

Currently, there are too many insurance companies available to give a generalization of reimbursement. However, based on the companies that we have worked with, UMR/UnitedHealthcare stands alone in payment on this procedure. Consequently, this evaluation was dependent on specific diagnosis codes we linked to 99000.

 Be aware that depending on the patient’s coinsurance, out-of-pocket expenses, deductible, or diagnosis code responsibility may be transferred to the patient. 

Always stay in the loop of provisions to your contracts with insurance companies regarding policies like these. It could mean a loss or a gain in revenue for your practice!

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As is standard procedure in medical billing practices, patients who do not cancel an appointment with at least 24 hours’ notice or do not attend the visit are considered no shows. Estimated no-show rates are 5-7%. While this may seem low, it decreases revenue, costs, you and your staff time and can affect patient results. 

Following are some tips that may provide some guidance on billing management for patient no-shows:

  • Always review patient contracts before billing no-show charges. For instance, Medicare patients can be billed directly, but providers will not receive payment from Medicare. In addition, all patients (regardless of insurance coverage) are charged the same, prohibiting Medicare patients from discrimination. 
  • Post your no-show fee policy on your website, in your office, and on patient paperwork such as appointment reminders. Also, ensure that staff verbally communicate to patients the no-show policy. 
  • Create a workflow where your staff is alerted to follow-up with patients who have missed appointments. They should advise patients why keeping appointments is vital for consistency in treatment. Of course, there should be exceptions for emergencies. Document no shows and follow calls in the patient’s file. Communication is key. 
  • Ensure scheduling systems can record no-shows. 15-minute appointments are standard for medical providers, while new patient visits could be 30-45 minutes. When no show rates or slow periods appear, book two 15 minute segments, thus allowing the remaining 30 minutes for longer appointments or new patients. 

Small practices, in particular, can be hurt by no-shows. If a practice with one physician has 45 minutes available, it may be nearly impossible to fill it on short notice. This is why providers require 24 or 48 hours’ notice for cancellation – providing time that another appointment could be scheduled and making up for lost revenue. 

The type of patients a practice has can also affect the no-show percentage. Specialists whose services are not covered by insurance or Medicaid are vulnerable to no-shows. Some practices charge a no-show fee when feasible, but that has its challenges. Medicaid does not allow a provider to bill a patient for missed appointments. If a patient is charged a no-show fee on a credit card, this is a self-pay charge and should be set up using a miscellaneous dummy code in your billing management system. 

Reminder services are available through electronic health record (EHR) systems. They can remind patients by email, text, or phone of their appointments and give them an option to confirm or reschedule if needed. It’s essential to communicate with the patient the importance of showing up and finding convenient times. 

Whatever method you use to advise patients of the consequences of no-shows, make it clear, concise, and effective communication. Train your staff accordingly on their duties in dealing with no-shows. This will assist in creating a thriving, beneficial practice for both you and your patients. 

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Copyright © 2021 all rights reserved.



Revenue cycle management is essential to operating all clinical and administrative data that enters the hospital and your practice. With the use of proper software assisting the process, it remains a laborious and complex procedure. In the case of hospitals, large amounts of data travel through several departments. Accuracy is critical to managing a patient’s hospital or office visit, from registration to bill payment. 

The daily maintenance of a practice’s revenue process should follow these nine steps: 

1) Pre-registration 

2) Registration 

3) Charge capture

4) Utilization review

5) Coding 

6) Claim submission

7) Remittance processing 

8) Insurance follow up 

9) Patient collections.  

As revenue cycle management expands, medical practices and facilities need to work as one unit. For goals to exceed expectations, the process must unify all departments. Data must be accurate and adequately communicated – ensuring staff knows their responsibility in adhering to revenue cycles. Therefore, practice managers must eliminate inconsistencies from everyday functions.


Pre-Registration is the collection of patient information before the visit. This collection consists of the patient’s:



Phone number/email address

Date of birth

Insurance information (identification number, policyholder, etc.)

Depending on the circumstances, the provider may want to know the patient’s health history. 

The entire pre-registration process should be done online at the patient’s leisure. This implementation into your front office’s workflow not only saves your practice time but it prepares the patient for the office visit. They can then address any issues before coming into the office, such as past-due balances, inactive insurance, or failed pre-authorization required for a visit.


The registration process should go smoothly if your patients complete the pre-registration sent to them the day before. Therefore, all that is left for them to do is verify all information is accurate. This information includes the financial policy of the office and the acknowledgment and assignment of benefits.

Charge Capture

Charge Capture is used by doctors and other health care providers to record services provided to patients. The practice must perform the charge capture through the use of electronic health systems. Electronic health records or EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users ( Once the physician signs off on the chart, it is then transmitted, reviewed, and processed for the billing process. 


Healthcare facilities should all have an external scrubbing system. After the physician enters procedures performed, they add the diagnoses and signs off on the chart for billing. However, before the claim gets sent out to the insurance company, the biller must ensure that the Evaluation and Management codes are appropriately utilized and that no expired diagnoses are attached. Taking the time to review this will prevent delays in claims processing and payment.

Remittance Processing and Insurance Follow-Up

The health care payment and remittance advice transaction is the transmission of either:

1) Payment, with information about the transfer of funds and payment processing from a health plan to a health care provider’s financial institution


2) Explanation of benefits or remittance advice from a health plan to a health care provider (

Remittance processing is vital to the functionality of RCM. For instance, if the facility and insurance company has an agreement that endoscopies are reimbursed at $2000 in-network, but the remittance states otherwise, the biller should immediately escalate this to the insurance company’s representative. The biller must take the same action if procedures are unpaid or pending payment after a certain period.

Patient Collections

The front office must receive the patient’s co-pay at the time of service. If they have a deductible AND a co-pay, the front office may deduct the co-pay from the estimated amount to be applied to the office visit. There should be a standard amount expected and made available to the front desk for reference. In addition, before procedures are performed in the office/facility that the insurance will not cover, there should always be a financial responsibility waiver signed by the guarantor and collected upfront. This workflow avoids unnecessary time spent on phone calls and more time focusing on today’s patients.


The primary objective of having an AR and RCM is to maintain the maximum cash flow into the practice by minimizing collection periods and associated costs. Well-managed offices and facilities create uniform processes to manage accounts receivables from when a patient schedules an appointment to final payment collection. Staff is adequately trained, and patient communication is clear. 

Having a consistent, reliable accounts receivable management process will assist your practice in riding these waves of uncertainty. In addition, efficiency in this area can significantly improve your bottom line profits.

Pro Initiative Billing is here to help!


Centers for Medicare & Medicaid Services. “Health Care Payment and Remittance Advice and Electronic Funds Transfer.” 20 September 2020. 19 October 2021.

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A patient’s chart should stand alone as an accurate record of their illness and treatment. It is a valuable medical and legal document. A complete assessment will provide continuity of care, quality statistics, mortality/ morbidity data collection, and accurate reimbursement. 

CDI professionals review of medical charts is quite possibly their most important responsibility. It is believed they can review 16-24 charts a day, depending on the facility size. A thorough evaluation is performed looking for incomplete, conflicting, illegible documentation of diagnoses, treatments, and procedures, in addition to measuring clinical care. 

Setting a clear goal for CDI patient chart review requires knowledge of reimbursement and quality standards. CDI professionals aim to convey the patient’s story from admission to discharge by examining, reviewing, and comprehending many pieces of information from varied sources and systems. This process requires extensive clinical sharpness, critical thinking, knowledge of coding, and quality practice management skills.

One of the most significant challenges in streamlining a medical chart review process is contending with varied organizational structures and focusing on different end goals, resulting in differing review emphases. This can be challenging as it requires access to upper management and negotiating with other departments with competing interests. Communication is key. 

A patient chart review should begin 24-48 hours after admission and/or when initial assessments have been completed. A good rule to follow could be reviewing a chart when the medical history and physical are conducted, followed by initial diagnostic testing. 

The CDI specialists focus changes with each subsequent review. They follow up on physician query responses, update codes, and possibly change their diagnosis based on the documentation of the patient’s care. 

CDI review of patient charts requires time and thought, and the process itself needs to be tracked and recorded. It should be clear, detail-oriented, and thorough. If a colleague picked up the chart for a re-review, they should be able to read and understand the reviewer’s thought processes and conclusions. 

Different types of medical chart reviews exist, and professionals performing reviews must be trained and experienced. 

Chart review for determining medical necessity. The most common type is preauthorization and hospital review. Non-urgent requests must be authorized before actually taking place. Reviews performed during a hospital stay aim to determine the length of stay, whether an extension is necessary, and to determine if an appropriate level of care is being administered. Insurers may use a company that reviews medical charts, and a hospital may use a dedicated team of physicians. Hospital reviews done by physicians do not directly affect payment of services. Primarily they are used to prevent payment denial by anticipating the insurer’s conclusions. 

Chart review for legal purposes. In legal cases where medical diagnoses and treatments are involved, courts require information from an expert to determine if the medical care is appropriate, if negligence occurred, or a compromise in medical ethics. Typically these reviews are administered by a medical review team hired by the defense lawyer or plaintiff. They review all medical documentation and prepare a statement of the services provided. 

Chart review for coding and clinical documentation. Such reviews are done in conjunction with hospitalization to correct documentation before a file is claimed with the insurer. CDI reviews require professionals with a background in nursing and closely work with coders. 

Chart review for insurance underwriting. Insurance companies determine how long an individual is expected to live and what medical issues are death risks. This factor determines insurance premiums. 

In addition, medical charts can be reviewed to use data for research projects. 

Medical chart reviews play an integral part in hospitals/healthcare systems to gather data while examining ways to enhance best practices. Patience, clinical and coding knowledge, and the ability to apply critical thinking to the case facts are essential skills for the CDI specialist. While serving as a record of care, it provides valuable medical insight and is a vital source of practice management. Perform in-house chart reviews quarterly for maximum production.

See below price plans offered by Pro Initiative Billing Svcs. for these services:

Chart Review
  • per provider 1 date of service
Chart Review
  • Up to 10 providers 5 dates of services

Message us for further inquiries!

How providers can support their billing staff while still getting paid what they should

The one thing that billers universally agree on is the struggle of having patients dispute charges performed during their office visits. Most patients do not care that the physician took their time with their examination and was able to arrive at a diagnosis during that visit. The only thing the patient cares about is their high deductible and having to pay it in 30 days or less.

For some of us billers, a phone call is automatically expected while reviewing the claims, we notice that an office visit has been billed in conjunction to a well visit. While this is not unusual in many practices, it then becomes a challenge when doctors do not have documentation to support billing a sick visit with a well. Below are key items to include in your charts to show necessity:

  • Patient requests you do additional tests not required or recommended during a well
  • Required or recommended tests performed during the well, resulted in further testing needed to be performed by you, your staff or referral to a specialist
  • Patient age required specific vaccines, but could not be carried out because of a fever or ailment
  • Performing a follow-up from a previous visit that is unrelated to the well visit (can include COVID testing upon request due to exposure)

The above suggestions should ALWAYS constitute an office visit but this is ultimately upon the physician’s discretion.

Following these guidelines will allow your billing staff to properly reiterate to your patients in an educated matter on why they are being billed separately during their well visits. However, it should also be taken into consideration that during a well visit, depending on the age of the patient, certain matters discussed should be part of their visit although the physician may have spent a considerable amount of time on said issue.

Physicians deserve to be reimbursed for their time. However, the overall goal is to not only practice good medicine, but to create an environment and relationship with their patients where they feel open and safe enough to discuss concerns without being billed for it.

Bottom line:

Back up your billing team by documenting appropriately. We are all in this together!

Have a quick question for us? Reach out to us here:

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Copyright © 2021 all rights reserved.

Documenting Your Charts For URI’s

Whether your field is in pediatrics, family medicine, allergy or pulmonology, documenting your charts is key to getting the proper reimbursement for your services. For providers in the previously mentioned fields, the diagnosis of Upper Respiratory Infections has become a common theme for obvious reasons (the pandemic). Below are points that must be hit to properly document and bill for your time and services:

Your exam with diagnostics and findings

Document the findings for breathing and how patient tolerated your tests performed in the office. Example:

The patient comes in for difficulty breathing, no fever reported.

Has no history of asthma.

Rapid COVID test results are negative.

You or your nursing staff perform a spirometry. Upon completion, your findings show parameters do not fall within the normal range. Points to hit:

  1. Make sure the values are documented inside the chart, along with your HPI, Family/Social History
  2. Is the patient exposed to cigarette smoke, pets or other outside sources?

Your treatment plan and referrals if applicable

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What To Expect With Our Free Consultation

Incase you were curious, here is what to expect when you connect with Pro Initiative Billing for your free consult:

  • Questions on your practice size
  • Why do we need to know this?
  • To evaluate whether our company is the right fit for you. We do have sufficient manpower to help up to 25 providers and/or physicians; however, if your practice contains more providers, we would either charge an additional fee or refer you to another company better suited for your practice size.
  • Are all providers credentialed?


If all providers are NOT credentialed, we need to then create a workflow so that they can still see patients (and you can still get paid) until they are credentialed. We would also need to know which plans you would like your providers to be enrolled in.

  • a) How many patients do your providers see daily?
  • b) How many providers are scheduled to see patients daily?


We need to determine how much time should be spent in processing the claims same day. This is also a good way for you as a client to evaluate the services we promise to provide and track revenue.

  • a) What EMR program are you currently using?
  • b) Are you satisfied with how it functions?


We need to know what we are working with and develop a plan to train our staff if it is a program we have not worked with before. This ensures maximum production!

  • a) Does your practice use Superbills?
  • b) If not, what is your workflow to track payments and or co pays?
    • Have you tracked the difference in revenue since you have stopped using Superbills?
    • Has revenue increased, decreased or remained the same?


If your practice does use superbills, we need to create a workflow so that we have secure access to them to get claims sent out same day.

If your practice does not use superbills, we need to again make sure a workflow is created so that all procedures performed are billed and all payments made by the patients are tracked and settled by end of day. If you do not currently have a workflow in place, no worries, we can help you create one!

It is important to track any modifications you have made within your practice to see if they are working. So we would need to review reports to see if there was any loss, gain or no change in revenue since the modification has been made. How far back we go to track your revenue would depend on how long it has been since the change has been made.

To get a proper evaluation of your practice and your need for our services, these questions are necessary to ask. Of course, there are a few more noteworthy inquiries, but we wanted to highlight these few to clarify any daunting questions for our future clients. It is important for you to know how we function as a team and the tools we need to function well!

We want to remind you that we offer trial services because we are THAT confident that we can increase your revenue AND empower you to grow your team with all A PLAYERS!

To set up your free consult today, please email inquiries to We hope to hear from you soon!