You Did the Work. Here’s Why You’re Not Getting Paid for It

Interventional Radiology

You’re performing complex procedures. Your reimbursement doesn’t reflect that.

Pitfall 1 — You documented the procedure. You didn’t document the decision.

Payers are increasingly denying IR claims not because the procedure was wrong — but because the clinical decision-making leading to it wasn’t captured. A two-line indication note doesn’t justify a complex vascular intervention. Your documentation needs to reflect the thought process, not just the action.

Pitfall 2 — Your imaging guidance is getting bundled away silently.

Some IR procedures include imaging guidance in the base code. Others don’t. The problem? Your billing team may be applying a blanket rule either way — either always bundling (and losing legitimate charges) or always separating (and triggering denials). Neither is correct. Ultrasound guidance for non-vascular drainage, for example, is separately billable and routinely missed.

Pitfall 3 — You’re getting paid for the procedure. Not for the vessels.

Additional vessel angiography, follow-through studies, and patch work each have their own codes — but they only get captured if your operative note explicitly names them. If your dictation says “additional vessels were evaluated,” that’s not enough. Payers need specificity.

Pitfall 4 — Your hospital-based work is being billed at office rates.

IR procedures done in a hospital outpatient department vs. your office-based lab are reimbursed under completely different fee schedules. If your billing reflects the wrong site of service, you’re either getting underpaid or flagged for recoupment — often months later.

Pitfall 5 — Your supervision level isn’t documented. That’s a compliance issue and a payment issue.

CMS requires documentation that the supervising physician was present at the appropriate level during the procedure. Without it, the professional component claim is vulnerable — not just to denial, but to audit.

Cardiovascular

Cardiology has the highest claim complexity per encounter of any specialty. Most practices collect less than 80 cents per dollar billed.

Pitfall 1 — Remote Device Monitoring: Correct Codes, Frequency Rules, and Billing Eligibility

Remote monitoring of implantable devices generates legitimate recurring reimbursement — but the correct codes, billing frequency, and eligibility to bill the technical component are each more specific than most practices apply.
Billing frequency by device type:

Pacemakers: every 3–6 months

ICDs: quarterly

Implantable loop recorders / cardiac monitors: monthly

Applying a monthly cycle to all devices will produce denials for pacemakers and ICDs billed too frequently.
Correct code structure — pacemakers and ICDs:

93294 — physician interpretation and report, single/dual chamber pacemaker (every 90 days)

93295 — physician interpretation and report, ICD (every 90 days)

93296 — remote interrogation, technical component (pacemaker and ICD systems)

Implantable hemodynamic monitors (e.g., CardioMEMS):

93297 — interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors, analysis, review(s), and report(s) by a physician or other qualified health care professional

93298 — interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac rhythm monitor system, including analysis of recorded heart rhythm data, analysis, review(s), and report(s) by a physician or other qualified health care professional

These are a distinct code family for hemodynamic monitoring devices only — they do not apply to pacemakers, ICDs, or loop recorders.
Loop recorder / implantable cardiac monitor: coding is payer-specific and does not use the 93297/93298 family. Historically billed under G2066 for the technical component; current billing requirements vary by payer and should be verified against each payer’s current policy before submitting.
Technical component eligibility: whether a practice can bill the TC depends on the contractual structure with any monitoring service and whether the practice meets applicable incident-to and supervision requirements. This is not determined by who performs the monitoring alone — practices using third-party services should review their arrangement against current CMS guidance and payer policy before billing the TC under the practice’s NPI.
Operational risk: monthly billing applied to all device types; 93297/93298 used for pacemaker, ICD, or loop recorder monitoring; TC billed without confirming the practice meets incident-to and supervision requirements under its specific vendor arrangement.

Pitfall 2 — Catheterization Coding: Combined Codes First, Separate Billing Where Independently Indicated

Right and left heart catheterization performed in the same session are not separately reportable when performed as part of a unified diagnostic evaluation. CPT provides combined codes for this scenario:
• 93460 — Right and left heart catheterization with coronary angiography
• 93461 — Right and left heart catheterization with coronary angiography and bypass graft evaluation
When both studies are performed as part of a single clinical workup, the combined code must be reported. Reporting separate codes in this setting will result in bundling edits or denial.
Separate reporting may be appropriate when right heart catheterization is performed as a distinct, independently indicated procedure, supported by clear documentation of separate medical necessity. In such cases, NCCI edits may require a modifier (e.g., -59 or X{EPSU}) to indicate a distinct procedural service; however, modifier use must be supported by documentation and should not be applied reflexively.
Diagnostic angiography at the time of PCI: When prior coronary angiography remains clinically adequate for decision-making, repeat diagnostic angiography performed at the time of PCI is not separately reportable. Separate reporting is appropriate only when a new diagnostic study is clinically necessary (e.g., new symptoms, change in clinical status, or inadequate prior imaging), and this must be explicitly documented. There is no fixed time interval that determines validity; the standard is clinical adequacy.
Operational risk:
• Reflexive unbundling when a combined catheterization code exists
• Reporting diagnostic angiography with PCI without documentation of a new clinical indication

Pitfall 3 — Prolonged Service Codes: Medicare and Commercial Payers Use Different Codes

Since the 2021 E/M overhaul, prolonged service codes can be added to a Level 5 visit when the encounter genuinely exceeds the time threshold. In cardiology — complex medication management, multi-device review, multiple active conditions — this happens regularly. The charge is almost never captured.
The applicable codes differ by payer:

Medicare: G2212 — each additional 15 minutes beyond the minimum time for a Level 5 outpatient visit. Medicare does not recognize CPT 99417 for this purpose.

Commercial payers: CPT 99417 — same function, but accepted only by payers that follow AMA guidelines. Many commercial payers do not accept 99417; verify payer-specific policy before applying it.

Inpatient / observation: CPT 99418

Submitting 99417 to Medicare will produce a denial. Submitting G2212 to a commercial payer that doesn’t recognize it will produce the same. A payer-specific mapping is required before applying prolonged service codes systematically.
Total time must be documented in the note — a statement of total time spent on the date of the encounter, including both face-to-face and non-face-to-face work. Without documented time, neither code is supported regardless of how long the visit took.
Operational risk: 99417 submitted to Medicare; G2212 or 99417 applied without a payer-specific acceptance list; time not documented in the note.

Pitfall 4 — EKG Interpretation: A Separate Signed Interpretation Is Required

When a physician interprets a tracing performed by another provider or at another facility, the interpretation component (CPT 93010) is separately billable — but only when a distinct, signed interpretation exists in the medical record. A checkmark, an initialed strip, or an incidental reference to the tracing in the visit note does not constitute a billable interpretation.
The interpretation must reflect independent physician judgment — the findings, their clinical significance, and the physician’s signature. It does not need to be a physically separate document, but it must be clearly identifiable as a distinct interpretation within the record: not embedded as a passing comment in the visit note, and not indistinguishable from the visit documentation. If a reader cannot identify the EKG interpretation as a discrete, signed clinical judgment, it will not support the charge on audit.
Operational risk: interpretation documented as a notation rather than a clearly separated signed finding; no workflow distinction between performing an EKG and interpreting one ordered or performed elsewhere.

Pitfall 5 — Stress Test Component Splitting: Bill What You Did, Not the Global

When a hospital or facility provides the technical component of a stress test and the cardiologist provides the professional component — supervision, interpretation, or both — the global stress test code cannot be billed by the physician. Billing the global code when the facility has already billed the technical component creates a duplicate billing situation.
The correct approach:

Physician supervises and interprets: bill the professional component with modifier -26. Supervision is included within the professional component — a physician who supervises and interprets is entitled to bill -26.

Physician interprets only (no supervision): bill with modifier -26, supported by a clearly identified signed interpretation report.

Physician supervises only, without interpretation: supervision alone does not generate a separately billable professional component in most stress test contexts. If no interpretation is performed and documented, there is no billable professional service.

Payers identify global/technical overlap through cross-claim edits and typically recoup the overpayment six to twelve months after the original payment.
Operational risk: global code used by default regardless of what the facility billed; modifier -26 not applied when the physician’s role is limited to the professional component; supervision alone billed without a corresponding interpretation.

Gastroenterology

GI procedures are frequently associated with elevated outpatient denial rates — many of which stem from documentation, modifier use, and misalignment with payer-specific billing rules rather than medical necessity itself.
Below are five high-risk areas where otherwise valid services are commonly underbilled, denied, or misprocessed.

Pitfall 1 — Screening-to-Diagnostic Colonoscopy: Modifier and Code Selection

When a screening colonoscopy results in an intervention (e.g., polyp removal, biopsy), the service must be coded based on what was performed, not the initial intent.
Medicare does not use standard CPT codes for screening colonoscopy. The correct starting codes are HCPCS G0105 (high-risk patients) or G0121 (average-risk patients). When the procedure converts to a therapeutic service and an intervention is performed, bill the applicable therapeutic CPT code (e.g., 45385) and append modifier PT to indicate the screening origin. If the colonoscopy becomes diagnostic but no intervention is performed, modifier PT does not apply.
Commercial payers subject to ACA preventive services requirements typically use modifier 33 — but only when an intervention is actually performed during the converted procedure. Self-funded ERISA plans may be exempt, and payer-specific policies must always be verified.
Note: Under the Consolidated Appropriations Act of 2021, patient coinsurance on converted screening colonoscopies is being phased out for Medicare beneficiaries through 2030. Correct modifier PT application is required throughout this transition to prevent improper patient cost-sharing.
Operational risk: using CPT codes instead of HCPCS G-codes for Medicare screening; applying PT or 33 on conversions where no intervention was performed.

Pitfall 2 — Endoscopic Interventions: Bundling vs. Separate Reporting

CPT 45381 (submucosal injection) and CPT 45382 (control of bleeding) operate under different rules and must not be treated identically.
45381 is separately reportable when performed for a clinically distinct purpose. Notably, 45381 and 45385 are not subject to an NCCI bundling edit — modifier -59 is generally not required for this pairing. Documentation must specify clinical indication, technique, and anatomical site.
45382 is subject to a hard NCCI rule: hemostasis is considered a standard component of every surgical endoscopic procedure. CPT 45382 cannot be separately billed for bleeding caused by the endoscopic procedure itself — there is no modifier that overrides this. Separate billing is appropriate only when bleeding originates from a distinct anatomical site, or when the patient returns in a separate session specifically to address bleeding.
Documentation stating only “hemostasis achieved” will not support separate reporting. Notes must explicitly identify the bleeding site, the technique used (e.g., electrocautery, hemoclip, injection), and the clinical indication — making clear that the event was distinct from routine procedural hemostasis.
Operational risk: assuming modifier -59 unlocks separate reimbursement for 45382 when bleeding was procedurally caused; documentation that describes outcome without describing the clinical event.

Pitfall 3 — Capsule Endoscopy: Prior Workup Requirement and Documentation

Capsule endoscopy codes: CPT 91110 (esophagus through ileum — the small bowel study); CPT 91111 (esophagus only).
Most MACs require documented prior upper endoscopy and colonoscopy before approving CPT 91110 on medical necessity grounds. To demonstrate this, claims should include ICD-10 codes Z98.890 (history of prior upper endoscopy) and Z98.891 (history of colonoscopy). Submitting only the symptom or indication code without these history codes is a leading cause of preventable medical necessity denials.
Importantly, MACs may request not just confirmation that prior workup occurred, but the exact dates and results of prior upper endoscopy and colonoscopy. Documentation should therefore record these specifics in the clinical record — not merely reference that prior studies were performed. Vague language such as “colonoscopy previously unremarkable” without dates or findings is unlikely to satisfy an audit request.
Documentation must function as a standalone diagnostic study report and explicitly include: clinical indication and results of prior workup, completeness of visualization (percentage of small bowel reached), preparation adequacy, and all relevant findings with location and characterization.
Operational risk: omitting ICD-10 history codes; recording prior workup without specific dates and results; treating capsule endoscopy reports like standard endoscopy notes.

Pitfall 4 — Biologic Infusions: Drug and Administration Capture

For in-office biologics (infliximab, vedolizumab, ustekinumab), billing requires capturing both the drug (J-code) and the administration service (time-based infusion codes). For Medicare physician office settings, administration is billed as 96413 (first hour) + 96415 (each additional hour). Clinical documentation must record infusion start and stop times.
JW/JZ modifier requirement — mandatory since July 1, 2023: CMS requires drug wastage modifiers on all single-dose biologic claims. Modifier JZ = no drug discarded; modifier JW = drug discarded (wasted amount billed on a separate line). Omitting JW or JZ on infliximab or biosimilar claims results in claim rejection under the current CMS policy.
Operational risk: omitting administration codes, underbilling drug units, or missing the JZ modifier.

Pitfall 5 — Anesthesia Models: Code Selection and Compliance

Anesthesia for GI procedures is separately billable only when the provider type, supervision structure, and medical necessity all meet applicable requirements. There is no universal ASA threshold that guarantees reimbursement — payer policies vary materially.
Code selection is critical and frequently mishandled:

CPT 00812 — anesthesia for screening colonoscopy in asymptomatic patients

CPT 00811 — anesthesia for diagnostic or therapeutic colonoscopy

CPT 00813 — combined upper and lower GI endoscopy in the same encounter

When a screening colonoscopy converts to a therapeutic procedure and an intervention is performed, the anesthesia code must follow: bill CPT 00811 with modifier PT. Continuing to bill 00812 after conversion results in incorrect patient coinsurance and is a common audit trigger.
Practices building in-house anesthesia programs must also verify billing eligibility, CRNA supervision compliance (rules differ significantly between Medicare opt-out and opt-in states), and contractual alignment before submitting claims.
Note: Commercial payers may apply anesthesia reimbursement rules that differ significantly from Medicare — including stricter medical necessity criteria, explicit exclusions for low-risk patients, or requirements for prior authorization. Verify payer-specific anesthesia policies before billing, and do not assume Medicare coverage criteria translate to commercial plan approval.
Operational risk: using 00812 after procedural conversion; pursuing anesthesia revenue without validating the compliance structure; assuming commercial payers follow Medicare rules.

Orthopedics

Orthopedics loses more money to global period mismanagement than almost any other specialty. But the problem goes beyond global periods — arthroscopy coding, injection documentation, fracture care sequencing, and DME compliance each carry their own distinct failure patterns.

Pitfall 1 — Global Period: Billable Visits Are Being Written Off Automatically

Within the global period, most post-op follow-up visits are bundled — expected. But visits for unrelated conditions, new injuries, or significant, separately identifiable issues are billable. The problem is that most EHR templates default to “post-op visit,” and the charge disappears automatically.
The modifier selection matters and is not interchangeable:

Modifier 24 — unrelated E/M visit during the post-op global period

Modifier 79 — unrelated procedure (non-E/M) performed during the global period

Using the wrong modifier is as likely to produce a denial as using none at all.
One important distinction: CMS and AMA define “unrelated” differently. CMS includes treatment of complications within the global package; some AMA/CPT guidelines allow separate billing for certain complications. Commercial payers may follow either standard — verify before applying modifiers.
Finally: frequent use of modifier 24 by a single provider within global periods can itself trigger a payer audit. Documentation must clearly support the unrelated nature of each visit where the modifier is applied.
Operational risk: EHR auto-bundling that eliminates charges without clinical review; modifier 24 and 79 used interchangeably; no documentation protocol to establish “unrelated” status.

Pitfall 2 — Arthroscopy: Add-On Codes Are Not Simply Overlooked — They Have Strict Billing Criteria

Operative reports for knee and shoulder arthroscopy frequently document chondroplasty, synovectomy, and loose body removal. These do not automatically generate separate charges — and the reason is not just that surgeons don’t flag them. Most of these codes are bundled by default and require specific clinical and documentation criteria to be separately billable.
Chondroplasty — knee (CPT 29877 / HCPCS G0289) CPT 29877 cannot be billed alongside other knee arthroscopy codes (29866–29889) — it is bundled into them. For Medicare patients, when chondroplasty is performed in a separate compartment during another knee arthroscopy procedure, the correct code is HCPCS G0289, not 29877. Documentation must specify the compartment in which chondroplasty was performed and confirm it was distinct from the primary procedure site.
Loose body removal (CPT 29874) Separately billable only when the loose body is larger than 5 mm or removed through a separate incision. Routine removal of small fragments during debridement does not support a separate charge.
Synovectomy — knee (CPT 29876) Separately billable only when pathological synovial disease is documented (e.g., rheumatoid arthritis, pigmented villonodular synovitis) and the synovectomy was performed in a compartment where no other arthroscopic procedure was carried out. “Cleaning out” the joint during a routine arthroscopy does not meet the threshold.
Shoulder arthroscopy Limited debridement (29822) and extensive debridement (29823) are bundled into any other shoulder arthroscopy procedure — with narrow exceptions: 29823 may be separately billable alongside 29824, 29827, or 29828 only if the debridement was performed in a different zone. Documentation must make the anatomical separation explicit.
Operational risk: treating these as overlooked add-ons rather than codes with hard billing criteria; missing G0289 for Medicare chondroplasty; documentation that confirms performance but not compartment or clinical indication.

Pitfall 3 — Injection Visits: Image Storage Is a Hard Billing Requirement

Billing ultrasound guidance for joint injections (CPT 76942) requires a permanently recorded image stored in the patient record — not just a note stating that guidance was used. If the image is captured but not saved, the code is unsupportable and the claim is audit-vulnerable.
This is not an area of interpretive ambiguity: the documentation requirement is explicit in CPT guidelines and consistently enforced across payers. Workflow — not clinical practice — is usually the failure point. Confirm that your injection workflow includes image capture, labeling, and permanent storage as a required step, not an optional one.
Operational risk: clinical practice is compliant but the administrative workflow doesn’t save the image; no periodic audit of injection claims against image documentation.

Pitfall 4 — Fracture Care Converting to Surgery: Modifier Sequencing, Not Just Documentation

If fracture care is initiated and the patient later requires surgery, the billing sequence is specific — and missing any step creates either a denial or a recoupment exposure.
Step 1 — The decision visit: When the decision to operate is made during an E/M visit, modifier 57 (Decision for Surgery) must be appended to that visit. Without modifier 57, the visit is treated as included in the surgical global package and will be denied or recouped.
Step 2 — The surgical claim: The surgical procedure code carries modifier 58 (staged or related procedure performed during the postoperative period) to indicate that the surgery follows an initial fracture care encounter. This distinguishes the surgical claim from a duplicate and establishes the correct billing sequence.
Step 3 — Documentation: The clinical record must clearly document the decision to operate as a new clinical judgment — not a continuation of fracture care. The indication for surgery, the findings that drove the decision, and the date of that decision must be explicit. Vague language such as “patient not improving, will proceed with ORIF” is insufficient if it does not establish a distinct decision point.
Billing both the fracture care global code and the surgical code without this sequence results in overlap of global periods — the payer will identify this and recoup the fracture care payment.
Operational risk: modifier 57 omitted from the decision visit; modifier 58 not applied to the surgical claim; documentation that implies continuation rather than a new clinical decision.

Pitfall 5 — DME Dispensing: ABN Requirements and Registration Prerequisites

When dispensing braces or splints that Medicare may not cover, a signed Advance Beneficiary Notice (ABN) must be obtained before dispensing. Without it, the practice cannot bill the patient if Medicare denies — the cost is absorbed by the practice.
Two distinctions that the ABN rule depends on:

Medically non-covered items (Medicare could cover but doesn’t in this case due to lack of necessity): ABN is required. If not obtained, the patient cannot be billed on denial.

Statutorily excluded items (Medicare never covers these by statute — e.g., orthopedic shoes in most circumstances): ABN is not required and does not shift liability. A voluntary notice may be given, but it does not create a billing right that wouldn’t otherwise exist.

Confusing these two categories leads practices to rely on an ABN for statutory exclusions where it provides no protection.
DMEPOS enrollment — the prerequisite most practices miss: Medicare DME claims must be submitted to the DME MAC, not the Part B MAC — a separate administrative contractor. To bill Medicare for dispensed items, the practice must hold a valid DMEPOS supplier number. Practices that dispense orthotics or braces without this enrollment cannot bill Medicare at all, regardless of ABN status. This registration gap is more fundamental than any ABN issue and affects a significant number of orthopedic practices that dispense items informally.
Operational risk: ABN not obtained before dispensing for medically non-covered items; confusing statutory exclusions with coverage determinations; dispensing DME without DMEPOS enrollment.

Physical Medicine & Rehabilitation

PM&R documentation requirements are among the most specific in medicine. Most EHR templates don’t meet them.

Pitfall 1 — Therapy Claims: What Medicare Actually Requires Today

The functional outcome reporting system that required G-codes and severity modifiers on every therapy claim was eliminated by CMS on January 1, 2019. Practices still operating under that framework are following rules that no longer exist.
What Medicare does require today:
Discipline modifiers must appear on every therapy claim to identify the treating provider type:

GP — physical therapy services

GO — occupational therapy services

GN — speech-language pathology services

Missing or incorrect discipline modifiers result in automatic denial.
KX modifier — when a patient’s therapy costs exceed the Medicare therapy threshold (the annual cap), the KX modifier must be appended to certify that services are medically necessary and that documentation supports continued treatment. Billing above the threshold without KX results in denial. Applying KX without supporting documentation creates audit exposure.
The medical records threshold amount is $3000 and will remain so until 2028.
Progress notes — Medicare requires a progress report at least every ten treatment days or once every 30 calendar days, whichever is less. The note must document the patient’s progress toward goals, the continued need for skilled therapy, and any changes to the plan of care. A missing or inadequate progress note can trigger denial of the entire interval — not just the visit on which it was due.
Plan of care certification — the referring or treating physician must certify the plan of care, and recertification is required at defined intervals. Claims submitted without a certified plan of care are not payable.
Operational risk: EHR templates not updated since 2019 still prompting for G-codes; KX modifier applied without auditing whether supporting documentation exists; progress note intervals not tracked systematically.

Pitfall 2 — Timed Codes: Two Different Counting Methodologies, Two Different Payers

Therapeutic exercise (97110), manual therapy (97140), neuromuscular re-education (97112), and other timed therapy codes are billed in 15-minute units. When session time doesn’t divide evenly into 15-minute increments, the 8-minute rule governs how units are counted — but the methodology differs depending on the payer, and applying the wrong one in either direction creates either revenue loss or an audit finding.
Medicare (CMS) — total time method: Add up all timed-code minutes across the entire session, then calculate units from that total. Example: 38 minutes of timed services = 2 units (38 ÷ 15 = 2 with 8 minutes remaining, which meets the threshold for a third unit only at 38+ minutes with appropriate composition). Each unit requires at least 8 minutes; a full unit requires 15.
Most commercial payers — AMA Rule of Eights: The 8-minute rule is applied to each timed code independently. A code with 8–22 minutes = 1 unit; 23–37 minutes = 2 units, and so on. The same 16 minutes split between two codes (8 minutes each) yields 2 billable units under AMA, but only 1 under CMS total-time method.
It is important to review the payer’s policies and guidelines to confirm the appropriate approach. Many practices apply a single methodology across all payers without recognizing these important distinctions.
Time must be documented in the clinical note for every timed code. A note recording only the procedure performed without start/stop times or total minutes will not support unit billing under either methodology.
Operational risk: single unit-calculation methodology applied across all payers regardless of rules; time not documented per code; no internal audit of unit calculations against actual session notes.

Pitfall 3 — E/M and EMG on the Same Day: Modifier -25 and the Commercial Payer Shift

Performing an E/M and an EMG on the same day is clinically legitimate, and both services are billable — but only when the E/M is documented as a separately identifiable service independent of the EMG, and modifier -25 is appended to the E/M code. Without modifier -25, the payer bundles the E/M into the procedure automatically and pays only one service.
Documentation must demonstrate that the E/M addressed a clinical question distinct from the decision to perform the EMG — not simply that both occurred on the same date. A note that reads as a pre-procedure assessment without independent clinical content will not support the modifier.
Commercial payer change — active since 2023–2024: A number of commercial payers, including several BCBS affiliates, have introduced automatic payment reductions of up to 50% on E/M services billed with modifier -25 alongside minor procedures. Medicare does not apply this reduction. Practices billing modifier -25 correctly under Medicare rules may still be losing revenue on commercial claims if they have not reviewed payer-specific policies. Correct modifier use is necessary but no longer sufficient to guarantee full E/M reimbursement across all payers.
Operational risk: modifier -25 omitted entirely; E/M documentation that doesn’t establish independent clinical content; no payer-level review of reimbursement rates on modifier -25 claims.

Pitfall 4 — Re-Evaluation vs. New Evaluation: The Criterion Is Clinical, Not Calendrical

The choice between a re-evaluation (CPT 97164 for PT, 97168 for OT) and a new evaluation (CPT 97161–97163 for PT, 97165–97167 for OT) is a clinical determination — not a function of how much time has passed since the last visit.
The correct criterion:

If the patient’s presentation relates to the same condition and existing plan of care — a re-evaluation is appropriate, regardless of the gap in care.

If the patient presents with a new or unrelated condition — a new evaluation is appropriate and reimbursed significantly higher.

The 60-day rule is not a clinical threshold — it is an administrative episode trigger: Medicare requires a new case to be opened when there has been a gap in therapy of 60 or more days. Opening a new case typically involves a new evaluation — but that is because a new episode of care has begun, not because 60 days elapsed. A practice that automatically upgrades to new evaluation based on a 60-day gap, without confirming the condition is new or unrelated, is miscoding. A practice that uses re-evaluation for a genuinely new condition is leaving revenue on the table.
Document the basis for the evaluation type explicitly: what is the condition being evaluated, is it related to a prior plan of care, and what clinical findings support the level selected.
Operational risk: re-evaluation used by default regardless of clinical context; new evaluation triggered automatically by elapsed time rather than clinical presentation; evaluation level not documented with explicit clinical rationale.

Pitfall 5 — NCCI Edits and Same-Session Therapy Codes: Not All Edits Are Bypassable

Certain therapy code combinations trigger NCCI bundling edits when billed for the same anatomical region in the same session. The instinct to drop one code and bill only the other is the wrong response — but so is assuming that modifier -59 always resolves the issue.
Two types of NCCI edits:

Modifier indicator “1” (soft edit): The edit can be bypassed with modifier -59 (or the more specific X-modifiers: XE, XS, XP, XU) when the services are genuinely distinct. For example, CPT 97140 (manual therapy) and CPT 97530 (therapeutic activities) may be billed together with modifier -59 — but only when they were performed in separate, distinct 15-minute intervals. Documentation must reflect that separation in time, not merely assert anatomical distinction.

Modifier indicator “0” (hard edit): The bundling is absolute. No modifier overrides it. Appending -59 to a hard edit does not produce payment — it produces a denial with a different remark code. Knowing which edits are hard before billing saves both the claim and the audit exposure.

For any combination flagged by NCCI, the documentation must support three things: that each service was medically necessary independently, that each was performed as a distinct intervention, and — for soft edits — that the time intervals were separate.
Operational risk: dropping bundled codes as a default rather than evaluating modifier eligibility; applying modifier -59 to hard edits where it has no effect; documentation that describes two procedures without establishing temporal or anatomical separation.

Pitfall 6 — Providing Treatment in the Practice of Physical Therapy Without Referral

a. In accordance with Education Law section 6731(d), a licensed physical therapist may provide a patient with treatment in the practice of physical therapy without a referral from a physician, dentist, podiatrist, or nurse practitioner, for 10 visits or 30 days whichever occurs first, provided the licensed physical therapist meets the following requirements:

the licensed physical therapist has practiced physical therapy on a full-time basis equivalent to not less than three years prior to beginning such treatment, meaning the licensed physical therapist has completed at least 4,320 clock hours of physical therapy practice over a minimum of 36 months anytime prior to beginning such treatment; and

the licensed physical therapist meets all requirements of subdivision (b) of this section relating to the notice of advice.

b. Notice of advice. A physical therapist providing treatment in the practice of physical therapy without a referral from a physician, dentist, podiatrist, or nurse practitioner, in accordance with Education Law section 6731(d) and the requirements of this section, shall advise the patient in writing prior to beginning treatment of the possibility that treatment may not be covered by the patient’s health care plan or insurer without a referral from a physician, dentist, podiatrist, or nurse practitioner and that treatment may be a covered expense if rendered pursuant to such referral.
This notice of advice shall be provided on a form, a copy of which shall be kept on file by the licensed physical therapist as a patient record and a copy of which shall be given to the patient. The notice of advice form shall include the following information:

a statement of such advice and a statement attesting that the patient has read the notice of advice;

the date treatment will begin;

the patient’s name and address;

the patient’s signature and date the patient signed the form;

the treating physical therapist’s name and address; and

the treating physical therapist’s signature and the date the physical therapist signed the form.

Mental Health & Behavioral Health

Behavioral health billing changed more between 2020 and 2024 than in the previous two decades. Most practices haven’t caught up.

Pitfall 1 — You’re billing a therapy code when a combined E&M + therapy code pays significantly more.

For psychiatrists and psychiatric NPs, billing a medical E&M with an add-on psychotherapy code (90833 for 30 min, 90836 for 45 min, or 90838 for 60 min) typically outpays a standalone therapy code for the same encounter — because it captures both the medication management and the psychotherapy separately. The E&M code requires modifier 25 to indicate it’s a separately significant service on the same date. This isn’t a billing trick. It’s the correct code for what you’re actually doing. Most practices never made the switch after the 2021 E&M changes.

Pitfall 2 — Your telehealth claims are using the wrong place of service — silently.

POS 02 and POS 10 carry different reimbursement rates. POS 10 pays at the higher non-facility rate, while POS 02 pays at the lower facility rate — a difference that shows up on every single telehealth claim. For example, Medicare reimburses 99213 at $107.63 under POS 10 versus $63.78 under POS 02. Several major commercial payers — including UHC, Health First, and Anthem BCBS — similarly apply reduced fees under POS 02.
The distinction matters more than the names suggest. POS 10 is not limited to patients who are literally at home. CMS has clarified that POS 10 applies whenever the patient is receiving care outside a facility where they would normally receive medical care — including from their car or workplace. POS 02 applies when the patient is at a location other than their home or a non-facility site. If your billing defaults to one code regardless of where the patient actually was, you’re either leaving money on the table or exposed to recoupment.

Pitfall 3 — Your primary care practice is running a collaborative care model and not billing for it.

If your primary care practice works with a consulting psychiatrist and a care manager to treat patients with behavioral health conditions, there are monthly billing codes (99492, 99493, 99494) that capture that work — and they’re among the most underbilled codes in all of medicine. Many eligible practices have never heard of them.

An important distinction: these codes are billed by the treating primary care physician, not the consulting psychiatrist. The psychiatrist’s work is a component of the model, but the claim is submitted by the PCP practice. If you’re a psychiatric practice acting as the consultant, this is a conversation to have with your referring PCPs — not a code you bill yourself.

Pitfall 4 — Your crisis encounters are being billed as routine visits.

When you provide crisis intervention — documented as such in the record — there are specific codes (90839, 90840) that reimburse at a higher rate than a standard visit. In non-facility settings, crisis psychotherapy is reimbursed at 150% of the standard fee schedule rate. If your EHR template doesn’t surface these codes, they won’t get billed. The clinical work is there. The revenue isn’t.

Pitfall 5 — Your group therapy documentation is your biggest audit exposure.

Commercial payers are increasingly scrutinizing group therapy claims. What they want to see: each patient’s attendance confirmed with a sign-in sheet reconciled before claim submission, the therapeutic purpose of the group, and individual participation notes for each patient reflecting their specific engagement in that session. “Patient engaged appropriately” is not sufficient and is a common trigger for a records request.

Optometry & Ophthalmology

Eye care is the only specialty with two entirely separate exam code sets — and most practices are using the wrong one.

Pitfall 1 — Your EHR is defaulting to E&M codes when Eye Visit codes pay more for the same encounter.

CPT has codes specifically designed for eye exams — 92002 through 92014 — that often reimburse higher than equivalent E&M codes, depending on payer and documentation structure. The key difference is what each code set requires you to document.
A standard E&M visit is built around chief complaint, history, review of systems, and medical decision-making. An ophthalmologic exam under the eye visit codes is a fundamentally different structure with its own element-based logic. For intermediate codes (92002/92012), at least three of the 12 recognized ophthalmologic exam elements must be documented. For comprehensive codes (92004/92014), all 12 elements are required — and the exam must include initiation of a diagnostic or treatment program (prescribing medication, ordering diagnostics, or arranging specialist services; “return in one year” does not qualify). The exam may include documentation of visual acuity, external exam, ocular motility, pupil responses, slit lamp, IOP, fundus, and ocular adnexa — but which elements are required depends on the level of service billed. Bill a comprehensive code with incomplete documentation, and the claim will be downcoded or denied on audit.
Your EHR’s standard E&M template is built around a different documentation logic entirely. Because of this, most practices default to E&M codes out of habit and underbill on nearly every encounter.

Pitfall 2 — You’re not billing refraction to commercial payers because Medicare doesn’t cover it.

Medicare explicitly excludes refraction (92015). But that exclusion applies to Medicare only — and even “bill it to commercial” isn’t a universal rule. Coverage varies by plan, and for some payers, refraction is a contractual adjustment, meaning you cannot bill the patient either. The right approach: review each participating contract, bill when permitted, and build your exception list from actual ERA responses rather than assumptions inherited from your Medicare workflow.
The patients most commonly affected are those with diabetes. Annual dilated eye exams are a clinical standard of care for diabetic patients — but refraction is a separate service and is not itself a medically necessary component of a diabetic eye exam. It may be clinically appropriate as part of a comprehensive visual assessment, and it is separately billable when performed — but it remains non-covered by most medical payers regardless of the diagnosis. If your practice has a blanket “don’t bill refraction” policy applied across all payers, you may be writing off services that some commercial plans will cover. Check the contract, bill when appropriate, and let the ERA guide your payer-specific policy.

Pitfall 3 — Your fundus photography charges aren’t surviving audit.

92250 requires a physician interpretation and a formal report — not just image capture by a technician. If your workflow captures the image and generates an auto-populated template that the physician signs without adding a distinct interpretation, the claim won’t hold up to a records request. The report should include clinical findings, interpretation, and where applicable, comparison to prior studies. The documentation needs to reflect independent physician judgment.

Pitfall 4 — You’re billing one punctal plug when you inserted two.

68761 is billable per plug. Bilateral insertion is typically billed as two units or with RT/LT modifiers, depending on payer requirements — check your contracts. This is one of those simple, recurring errors that compounds into significant annual revenue loss, and it’s almost always a template default, not a clinical decision.

Pitfall 5 — Your glaucoma suspect patients are being billed under the wrong diagnosis — and losing their coverage.

Medicare provides a specific glaucoma screening benefit for high-risk patients — including those with diabetes, a family history of glaucoma, or ocular hypertension — but only when billed with the appropriate ICD-10 codes: H40.0x (glaucoma suspect) or H40.05 (ocular hypertension). This isn’t simply “more frequent exams” — it’s a distinct coverage benefit with its own eligibility criteria. Billing a routine exam diagnosis for these patients eliminates that coverage entirely. The clinical picture is in your chart. The right diagnosis often isn’t on the claim.