Medical Billing is as Tough as Keeping Score in Tennis
Love equals zero?
I happened to see Wimbledon tennis on television. It reminded me of the short time when I tried to learn to play tennis. When you learn any new sport, you are taught the physical skills as well as the rules. The physical skills are usually easy to grasp but hard to perfect. The basic rules are usually the opposite. But I admit I was confused by the scoring system in tennis.
For those who do not know it, I will let Wikipedia explain: “… scores from zero to three points are described as ‘love’, ‘fifteen’, ‘thirty’, and ‘forty’ respectively.”
So points 0 to 3 are not just 0 to 3? And points 1 and 2 are each worth 15, but point 3 is worth only 10? Who came up with that? The unusual scoring does not stop there, but I think I have made my point.
That is only part of my point. In tennis, in life and in medical billing, we often face rules that seem illogical or more complex than they need to be. We have to accept them and develop ways to work with them.
Point one (fifteen in tennis): Referral required
The term referral has two related but distinct meanings in medicine.
In the past, a physician referral meant the current provider recommended that you see a specific colleague for your condition. Dr. Kildare would say, “Mrs. Jones, I believe you should see a dermatologist for that suspicious area. I would like to contact Dr. Welby over on Main Street. The nurse will give you his number.” Mrs. Jones would call Dr. Welby’s office, go in and have her problem addressed.
Then insurance plans developed the managed care model. The term referral came to mean a written order from the primary care provider or the insurance company that gives the patient permission to see a specialist. In the early days of managed care, and still today with new enrollees, patients often assume that Dr. Kildare’s verbal referral to Dr. Welby is what the insurance company means by a referral.
The conversation often goes in circles:
Staff: “Welcome to Dr. Welby’s office. May I have your referral please, Mrs. Jones?”
Mrs. Jones: “Dr. Kildare referred me.”
Staff: “I see. Is Dr. Kildare your primary care physician?”
Mrs. Jones: “Yes, and he told me to see Dr. Welby.”
Staff: “Did you bring your referral?”
Mrs. Jones: “I told you Dr. Kildare referred me to Dr. Welby.”
Staff: “I understand, but your insurance company requires a referral for your visit.”
Mrs. Jones: “What does my insurance have to do with it? My doctor referred me here.”
The best way to prevent these frustrating conversations is to get complete insurance coverage information from the patient as soon as the appointment is made. If you learn that a referral is needed, tell the patient right away and explain the situation. You may still have the conversation above, but it will not be at your front desk with a waiting room full of patients. You can also contact the primary care physician’s office directly to get the referral faster.
You can use the Real Time Eligibility function in Iridium Suite practice management software to verify insurance coverage quickly before patient visits.
Prior authorization
Prior authorization is another area where billing staff often have little control. A growing number of managed care plans enforce pre-authorization requirements and processes. We know that any procedure of significant complexity or cost needs authorization under the payer’s protocols.
Some payers find that reviewing the requests takes so much work that they have contracted the reviews out to third-party utilization management companies like MedSolutions, Availity and CoreSource. Routine requests are often fairly quick. But you can run into problems when the provider orders a procedure that does not fit the payer’s predetermined scenarios. These utilization standards are based on commonly accepted medical guidelines. Billers know that some patients have special circumstances. In those cases, the billing staff must make a strong case to the payer.
Iridium Suite billing software lets you mark when a payer requires authorization for services. When this is marked on a patient account, every charge added is checked against that requirement, and the system notifies the user when the authorization is missing. This prevents payer denials and improves your chances of quick and correct claim payment.
Point two (thirty in tennis): Denials
We all dislike denials and try to prevent them, but they still happen. One type, described by claim adjustment reason code 97, can be avoided fairly easily:
“The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.”
This denial is often the result of the National Correct Coding Initiative (NCCI) edits. This data file contains HCPCS codes in pairs. Each pair shows that the procedure in column 2 is part of the more comprehensive procedure in column 1.
Compare it to buying a car. You would not expect a separate bill for the engine, because the engine is included. But if the engine needs an upgrade, that would be a separate charge.
In medical billing, some services are usually included, but extenuating circumstances can apply. For code pairs marked with a “1” in the NCCI data file, we may add modifier 59 to override the edit. Use this process with care. The documentation must state specifically why the included service should be considered a separate service.
How do billers remember which codes conflict and which edits can be overridden? The best way is an integrated claim scrubber in your billing software. Iridium Suite practice management software contains all of the NCCI edits, and users can request custom scrubber rules for the billing situations of their practice or specialty.
Another common denial is for exact duplicate services, claim adjustment reason code 18. Simple data entry errors cause many of these. Too many duplicate claim entries can make the practice’s accounts receivable reports look inaccurate, with more contractual write-offs than expected. The Iridium Suite scrubber also notifies users of duplicate code entries before submission to prevent these problems.
Point three (forty in tennis): Non-covered services
From many years of work in radiation oncology, I became very familiar with denials for non-covered services, or lack of medical necessity. These are procedures that are performed but fall outside the commercial payer’s medical policies, or, for Medicare, outside the National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs).
Medical billers must know the procedures performed in their office in detail, along with each payer’s coverage exceptions. This often means many hours of research on commercial payer websites to find and review the medical payment policies or coverage guidelines. CMS has a well-organized search tool, the Medicare Coverage Database, that makes this information much easier to find for Medicare beneficiaries.
Iridium Suite practice management software has many advanced functions to help you optimize your workflow. You can schedule a free demo.
Once the research is complete, share the information with other office staff, especially those who schedule procedures. Set up an office procedure to alert the right staff when these services are planned for a patient. It is much easier to handle the situation before the service is provided.
More than once, I had this conversation with the radiation oncologist:
Me: “Sally, the schedule coordinator, told me you are ordering IMRT for Mr. Jones. I checked the coverage for IMRT for Mr. Jones, and Medicare will not cover it for that diagnosis.”
Dr.: “IMRT is necessary for this patient. It is the appropriate and safest treatment for his condition.”
Me: “If we perform this procedure, it will be denied.”
Dr.: “I am going to provide the best care for the patient. Can we appeal it?”
Me: “Yes, we can appeal it, but it may still not be covered.”
Dr.: “I don’t care. It’s my job to help the patient, and this is what he needs. If we don’t get paid, that’s fine.”
Me: “Okay. Then I need you to be very specific in your documentation so I can use it for the appeal. The more details you include that justify your treatment choice, the stronger our case.”
Dr.: “I will take care of the documentation.”
As I expected, the claims were denied. But because I had discussed it with the physician beforehand, the documentation was thorough. Most of the time, the denials were overturned on appeal.
Commercial payers often allow a pre-determination review for procedures that may fall outside their coverage guidelines. I have seen these reviews take up to 30 days, so it is important to start as soon as possible. The notification process described above helps you do that.
Make thorough communication throughout the medical practice a top priority. It helps the billing staff get the best claim reimbursement for the practice.
What has changed since this was written
- IMRT delivery codes changed on January 1, 2026. The IMRT, IGRT and G-code delivery families were replaced by treatment delivery levels 77402, 77407 and 77412, so coverage checks and appeals for IMRT now involve the new codes. See the 2026 radiation treatment delivery codes.
- Medicare Advantage prior authorization has deadlines. Since January 1, 2026, Medicare Advantage plans must decide standard prior authorization requests within 7 days and give a reason for each denial. See radiation therapy prior authorization in 2026.
- MedSolutions is now eviCore. MedSolutions merged with CareCore National in 2015 to form eviCore healthcare, which manages radiation oncology reviews for several payers.
- Modifier 59 has more specific alternatives. Since January 1, 2015, modifiers XE, XS, XP and XU can be used in place of 59 to describe a distinct service. See CMS says modifier 59 needs an assist.