Internal Medicine Medical Billing Services

Most practices are, and it is rarely deliberate. Physicians worry about audits and default to a middle level even when the note supports more. A patient with three unstable chronic conditions and a medication change is not a mid-level visit. We audit a sample of your notes against the level billed and show you the gap in dollars before changing anything.

Three things: a patient with two or more chronic conditions expected to last a year, documented consent to the service, and a time log showing the qualifying minutes in that calendar month. The work can be done by clinical staff under supervision. Most practices already do the coordination. What is missing is the consent record and the time tracking.

They are separate services with different requirements. A wellness visit centres on risk assessment, a prevention plan, and screening review rather than a head-to-toe exam. Many plans cover the wellness visit at full benefit but not a routine physical. Billing one when you performed the other creates either a denial or an unexpected patient balance.

Yes, when the problem work is significant and separately documented. The note has to stand on its own for the problem, with its own history, exam, and decision making. Then the appropriate modifier is added. If the problem is simply mentioned during the preventive exam, it is not separately billable and the claim will not survive review.

Usually because chronic conditions are documented once and then carried silently in the chart. Risk adjustment resets annually, so a condition coded last year has to be addressed and coded again this year to count. We run a comparison report showing which diagnoses appeared last year but not yet this year, so your team can close the gap at the next visit.

There are two. Interactive contact with the patient must happen within a set number of business days after discharge, and the face-to-face visit must occur inside a defined window based on complexity. Both have to be documented with dates. Practices commonly do the follow-up but miss the contact deadline, which makes the entire service unbillable.

Whichever the documentation supports better. Time works well for long counselling visits and care coordination days. Decision making usually wins for complex patients seen efficiently. Our coders check both paths on every note and bill the one that is properly supported. Physicians only need to record total time on the date of service to keep that option open.

They need their own rules. Medicare Advantage plans set their own prior authorization requirements, referral rules, and filing deadlines, and they vary plan to plan within the same market. Risk adjustment also matters more with these payers. We maintain plan-level rules for every Medicare Advantage contract you hold rather than treating them all as Medicare.

Yes, for the right visit types. Chronic disease follow-up, medication management, and results review work well remotely. What matters is documentation: the modality used, patient consent, both locations when required, and clinical content that supports the level. Commercial payers do not all follow government rules here, so we track telehealth policy payer by payer.

Charge lag and clean claim rate usually improve within the first month, since those depend on process rather than payer behaviour. Coding level changes show up in the second and third month as new claims adjudicate. Recovery from aged accounts receivable takes longer. We report on all three separately so you can see which gains came from where.