The denial pattern
Patients change jobs, plans and employers between annual visits. When the practice bills the plan on file, the claim comes back CO-27 — coverage terminated — and the real payer may by then be past its filing window.
How we prevent it
- Eligibility verified before every visit, not just new patients
- Plan changes caught and registration updated before the claim
- Referral requirements checked for HMO and managed-care plans
- Preventive and problem-oriented visits coded correctly on the same day
- Denied claims rebilled to the correct payer inside the deadline
Preventive and problem visits on the same day
A patient who comes in for an annual physical and raises a new problem can be billed for both: the preventive visit (99381–99397) and a problem-oriented E/M visit with modifier 25 — but only when the note documents a separately identifiable problem. Get it wrong one way and the practice loses earned revenue; get it wrong the other way and the patient is surprised by a bill for a visit they thought was free. We code it from the documentation and send queries back when the note doesn't separate the two.
Chronic care and the services between visits
Primary care increasingly includes billable work outside the exam room: annual wellness visits for Medicare patients, chronic care management, transitional care after a hospital discharge, and care coordination. Each has its own documentation and time requirements, and each is missed revenue if it is delivered but not captured. We check that what was documented is billed, and that what is billed was documented.