Medical Billing & Coding

MedNexa Health - Service - Medical Billing & Coding

Accurate claim submission and compliant coding for maximum reimbursement.

Medical billing and coding is the core of your revenue cycle. Every service you provide must be accurately translated into standardized codes and billed to insurance companies for payment. Our team of certified coders and experienced billing specialists ensures every claim is coded correctly, submitted cleanly, and processed quickly for maximum reimbursement.

What’s Included:

Professional Medical Coding:

ICD-10 Diagnosis Coding:

  • Comprehensive diagnosis code selection from clinical documentation
  • Specificity and detail to highest level available
  • Laterality, episode of care, and encounter type coding
  • Combination codes when appropriate
  • Multiple diagnosis coding in correct priority order
  • Code first, use additional code, and excludes notation compliance
  • Manifestation and underlying condition coding
  • External cause coding for injuries and adverse events
  • Z-codes for screening, history, and status documentation

CPT Procedure Coding:

  • Evaluation and Management (E/M) level selection based on documentation
  • 2021 E/M guidelines implementation (time or MDM-based)
  • Surgical procedure coding with correct approach and extent
  • Medicine and diagnostic procedure coding
  • Anesthesia coding with time units and modifiers
  • New vs. established patient determination
  • Consultation vs. referral distinction
  • Preventive visit vs. problem-oriented visit coding

HCPCS Level II Coding:

  • Supply and material coding (drugs, devices, DME)
  • Injection and infusion coding
  • Ambulance and transportation services
  • Orthotics, prosthetics, and medical supplies
  • Temporary and miscellaneous codes
  • Medicare-specific codes and requirements

Modifier Application:

  • Anatomical modifiers (LT, RT, E1-E4, FA-F9, TA-T9)
  • Service-related modifiers (25, 59, 91, 76, 77, 78, 79)
  • Multiple procedure modifiers (51, 50)
  • Professional component/technical component (26, TC)
  • Assistant surgeon and co-surgeon modifiers
  • Reduced services and discontinued procedures
  • Telemedicine and place of service modifiers
  • Proper modifier sequencing

Coding Compliance:

  • NCCI (National Correct Coding Initiative) edits review
  • MUE (Medically Unlikely Edits) compliance
  • Correct Coding Initiative (CCI) bundling rules
  • Global surgical package compliance
  • Appropriate coding of bilateral procedures
  • Incident-to billing rules for auxiliary staff
  • Split/shared E/M coding for facility and professional
  • Teaching physician documentation requirements

Medical Billing Services:

Charge Entry & Review:

  • Daily charge entry from encounter forms, EHR, or charge tickets
  • Charge lag monitoring (goal: 24-48 hours from service)
  • Charge capture audits to ensure all services are billed
  • Superbill review for completeness and accuracy
  • Pricing verification and fee schedule application
  • Service date, place of service, and provider verification
  • Diagnosis-procedure code linkage review

Electronic Claim Submission:

  • EDI (Electronic Data Interchange) claim transmission
  • Clearinghouse submission for claim scrubbing
  • Direct payer submission when required
  • Paper claim generation for payers without electronic capability
  • Attachment submission (medical records, operative reports, etc.)
  • Real-time claim status tracking
  • Electronic claim acknowledgment monitoring

Claim Scrubbing:

  • Pre-submission error checking and correction
  • Demographic and insurance information validation
  • Diagnosis-procedure code compatibility
  • NCCI edit checking before submission
  • Missing modifier identification
  • Medical necessity screening
  • Timely filing deadline verification
  • Duplicate claim prevention

Clean Claim Submission:

  • First-pass acceptance rate goal: 95%+
  • Rejection resolution within 24 hours
  • Electronic payer acknowledgment tracking
  • Clearinghouse rejection reports monitoring
  • Immediate correction and resubmission
  • Root cause analysis of recurring rejections

Payment Posting:

Insurance Payment Processing:

  • Electronic remittance advice (ERA) posting daily
  • Paper EOB posting for non-ERA payers
  • Payment application to correct patient accounts
  • CPT-level payment posting for accurate tracking
  • Contractual adjustment posting
  • Write-off posting per payer contracts
  • Denial and reversal posting with reason codes
  • Claim-level notes for unusual payments or issues

Patient Payment Processing:

  • Copay, coinsurance, and deductible posting
  • Credit card and ACH payment processing
  • Check and cash payment recording
  • Online patient portal payment posting
  • Payment plan setup and recurring payment processing
  • Overpayment identification and refund processing
  • Unapplied payment management

Payment Variance Analysis:

  • Expected vs. actual payment comparison
  • Underpayment identification and appeals
  • Contract compliance verification
  • Incorrect payment investigation
  • Recoupment and offset analysis
  • Bundle and unbundle payment verification

Patient Billing:

Statement Generation:

  • Monthly patient statement generation
  • Clear, easy-to-understand statement format
  • Itemized services with date, description, and charges
  • Insurance payment and adjustment details
  • Current balance and amount due
  • Payment options and methods
  • Billing inquiries contact information
  • Multiple statement formats available (mail, email, patient portal)

Patient Communication:

  • Friendly payment reminder calls for overdue balances
  • Payment plan options and setup
  • Financial hardship program information
  • Charity care and sliding fee scale guidance
  • Medical bill negotiation assistance
  • Clear explanation of insurance benefits and patient responsibility
  • Balance billing communication for out-of-network services

Specialty-Specific Billing Expertise:

We have deep expertise in billing for all medical specialties:

  • Primary Care: Preventive visits, chronic disease management, annual wellness visits
  • Behavioral Health: Psychotherapy, psychiatric evaluation, add-on codes, time-based billing
  • Surgery: Global surgical packages, modifier usage, multiple procedure rules
  • Anesthesia: Time-based billing, modifier usage, physical status modifiers
  • Radiology: Professional vs. technical components, contrast administration
  • Laboratory: Panel vs. individual test billing, ABN management
  • Physical Therapy: Timed codes, units calculation, maintenance therapy
  • Cardiology: Diagnostic testing, stress tests, echocardiograms, cardiac catheterization
  • Gastroenterology: Endoscopy procedures, multiple polyp removal, biopsy coding
  • Dermatology: Destruction procedures, lesion count, biopsy coding

Facility & Professional Billing:

  • Hospital-based provider professional billing (modifier 26)
  • Facility billing (UB-04 claims)
  • Place of service determination
  • Split/shared billing for collaborative care
  • Inpatient consultation vs. subsequent care

Telemedicine Billing:

  • Synchronous telehealth coding (modifier 95, GT)
  • Originating site vs. distant site billing
  • Audio-only visit billing (new codes)
  • COVID-19 public health emergency flexibilities
  • State-specific telemedicine billing rules
  • Interstate telemedicine compliance

Additional Billing Services:

  • Secondary and tertiary insurance billing
  • Coordination of benefits processing
  • Workers’ compensation billing
  • Motor vehicle accident billing
  • Veterans Affairs and TRICARE billing
  • Medicare Advantage plan billing
  • Self-pay and uninsured patient billing

Compliance & Quality Assurance:

  • HIPAA-compliant processes and systems
  • OIG compliance program guidelines
  • Fraud and abuse prevention
  • Regular coding audits (5-10% of claims)
  • Coder continuing education and certification maintenance
  • E/M level distribution analysis
  • Upcoding and downcoding prevention
  • Documentation improvement feedback to providers

Technology & Integration:

  • Practice management system integration
  • EHR integration for automated charge capture
  • Real-time eligibility checking integration
  • Electronic remittance advice (ERA) auto-posting
  • Patient portal integration for online payments
  • Clearinghouse integration for claim submission
  • Reporting dashboard with real-time metrics

Performance Metrics:

  • Clean claim rate: 95%+
  • Days to submission: <24-48 hours from service
  • First-pass acceptance rate: 95%+
  • Collection rate: >95% of expected reimbursement
  • Charge lag: <2 days average
  • Coding error rate: <2%

Benefits:

  • Maximize reimbursement with accurate, compliant coding
  • Accelerate cash flow with prompt claim submission
  • Reduce claim denials and rejections
  • Ensure coding compliance and audit readiness
  • Free staff from complex billing tasks
  • Access certified coders without hiring costs
  • Stay current with annual code updates
  • Improve provider documentation through feedback

Turnaround: Claims submitted within 24-48 hours of receiving complete documentation