# Vizora

> Medical billing and revenue cycle management for US healthcare practices.
> We reduce claim denials, shorten days in AR, and recover revenue practices
> would otherwise write off. Pricing starts at 3% of net
> collections (typically 3–6%). 25 specialty pages,
> 50 state pages, 12 services.
> Last reviewed: 2026-08-20

## What Vizora does

Vizora operates the revenue cycle for healthcare practices: medical coding,
claim scrubbing and submission, payer follow-up, denial management and appeals,
accounts receivable recovery, eligibility verification, prior authorization,
provider credentialing, patient collections and practice analytics.

Practices typically engage us when their denial rate exceeds 10%, when AR is
aging past 90 days, or when billing depends on one person whose absence stops
collections.

## Pricing

percentage of net collections. Starts at 3%; typically
3–6% depending on practice size, specialty and claim volume.
No setup fees. Denial appeals are never billed separately.
Machine-readable detail: /pricing.md

## Start here

- [Services overview](/services): all 12 services
- [Pricing](/pricing): rates, what is included, what is not
- [Comparisons](/compare): in-house vs outsourced and four other decisions
- [Free billing audit](/contact): denial rate, AR aging and clean claim rate reviewed against benchmarks
- [Sitemap](/sitemap): every page on the site

## Free tools and reference data (no signup, no email required)

- [Revenue Leak Calculator](/tools/revenue-leak-calculator): estimates annual revenue lost to denials using published MGMA, Premier and Optum benchmarks
- [Denial Code Lookup](/tools/denial-code-lookup): all 190 CARC and RARC codes explained, with the fix and the prevention for each
- [CPT Modifiers Explained](/modifiers): 24 modifiers, each with the misuse cases that cause denials — not only when they apply
- [RCM Benchmarks](/resources/rcm-benchmarks): current industry benchmarks, every figure attributed to a named publisher, dataset and year
- [Glossary](/glossary): 41 medical billing terms defined
- [Resources](/resources): primary sources — CMS, X12, MGMA, HHS — that govern how claims are paid

## Denial codes in depth

Long-form guides for the 50 most-searched codes — each with a worked
example, the mechanism behind the code, and the modifiers that resolve it.
The remaining codes are in the lookup tool above.

- [CO-97](/denial-codes/co-97): The benefit for this service is included in the payment for another service already adjudicated
- [CO-45](/denial-codes/co-45): Charge exceeds the fee schedule or contracted maximum allowable
- [CO-16](/denial-codes/co-16): Claim or service lacks information needed for adjudication
- [CO-50](/denial-codes/co-50): Non-covered service because it is not deemed a medical necessity
- [CO-29](/denial-codes/co-29): The time limit for filing has expired
- [PR-204](/denial-codes/pr-204): Service not covered under the patient's plan, patient responsibility
- [CO-15](/denial-codes/co-15): The authorization number is missing, invalid, or does not apply
- [CO-197](/denial-codes/co-197): Precertification, authorization or notification absent
- [CO-4](/denial-codes/co-4): Procedure code inconsistent with the modifier used, or a required modifier is missing
- [CO-11](/denial-codes/co-11): The diagnosis is inconsistent with the procedure
- [CO-18](/denial-codes/co-18): Exact duplicate claim or service
- [CO-22](/denial-codes/co-22): This care may be covered by another payer per coordination of benefits
- [CO-27](/denial-codes/co-27): Expenses incurred after coverage terminated
- [CO-31](/denial-codes/co-31): Patient cannot be identified as our insured
- [CO-59](/denial-codes/co-59): Processed based on multiple or concurrent procedure rules
- [CO-96](/denial-codes/co-96): Non-covered charges
- [CO-109](/denial-codes/co-109): Claim is not covered by this payer or contractor
- [CO-119](/denial-codes/co-119): Benefit maximum for this time period or occurrence has been reached
- [CO-151](/denial-codes/co-151): Payment adjusted because the payer deems the information submitted does not support this many services
- [CO-167](/denial-codes/co-167): This diagnosis is not covered
- [CO-B15](/denial-codes/co-b15): This service requires that a qualifying service or procedure be received and covered
- [PR-1](/denial-codes/pr-1): Deductible amount
- [PR-2](/denial-codes/pr-2): Coinsurance amount
- [PR-3](/denial-codes/pr-3): Copayment amount
- [CO-140](/denial-codes/co-140): Patient or insured health identification number and name do not match
- [CO-204](/denial-codes/co-204): Service, equipment or drug is not covered under the patient's current benefit plan
- [PR-49](/denial-codes/pr-49): Routine or preventive examination not covered
- [CO-55](/denial-codes/co-55): Procedure or drug is deemed experimental or investigational
- [CO-40](/denial-codes/co-40): Charges do not meet qualifications for emergent or urgent care
- [PR-B7](/denial-codes/pr-b7): Provider was not certified or eligible to be paid for this procedure on this date of service
- [CO-185](/denial-codes/co-185): The rendering provider is not eligible to perform the service billed
- [CO-183](/denial-codes/co-183): The referring provider is not eligible to refer the service billed
- [CO-198](/denial-codes/co-198): Precertification, authorization or notification exceeded
- [CO-165](/denial-codes/co-165): Referral absent or exceeded
- [CO-62](/denial-codes/co-62): Payment denied or reduced for absence of, or exceeded, pre-certification
- [CO-107](/denial-codes/co-107): The related or qualifying claim was not identified on this claim
- [CO-236](/denial-codes/co-236): This procedure or combination is not compatible with another procedure provided on the same day
- [CO-231](/denial-codes/co-231): Mutually exclusive procedures cannot be done on the same day
- [CO-234](/denial-codes/co-234): This procedure is not paid separately
- [CO-B10](/denial-codes/co-b10): Allowed amount reduced because a component of the basic procedure was already paid
- [CO-150](/denial-codes/co-150): Documentation does not support this level of service
- [CO-17](/denial-codes/co-17): Requested information was not provided or was insufficient
- [CO-252](/denial-codes/co-252): An attachment is required to adjudicate this claim
- [MA130](/denial-codes/ma130): Claim contains incomplete or invalid information; no appeal rights are afforded
- [CO-26](/denial-codes/co-26): Expenses incurred prior to coverage
- [CO-32](/denial-codes/co-32): Our records indicate the patient is not an eligible dependent
- [CO-253](/denial-codes/co-253): Sequestration reduction in federal payment
- [CO-147](/denial-codes/co-147): Provider contracted rate expired or is not on file
- [CO-222](/denial-codes/co-222): Exceeds the contracted maximum number of hours, days or units for this period
- [CO-19](/denial-codes/co-19): This is a work-related injury and is the liability of the workers compensation carrier

## CPT and HCPCS modifiers

Each page covers when the modifier applies and, more usefully, when it does
not — the misuse cases are what produce denials and audit findings.

- [Modifier 25](/modifiers/25): Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure
- [Modifier 59](/modifiers/59): Distinct procedural service
- [Modifier 26](/modifiers/26): Professional component
- [Modifier TC](/modifiers/tc): Technical component
- [Modifier 50](/modifiers/50): Bilateral procedure
- [Modifier 51](/modifiers/51): Multiple procedures
- [Modifier 24](/modifiers/24): Unrelated evaluation and management service by the same physician during a postoperative period
- [Modifier 57](/modifiers/57): Decision for surgery
- [Modifier 78](/modifiers/78): Unplanned return to the operating or procedure room by the same physician for a related procedure during the postoperative period
- [Modifier 79](/modifiers/79): Unrelated procedure or service by the same physician during the postoperative period
- [Modifier 76](/modifiers/76): Repeat procedure or service by the same physician
- [Modifier 91](/modifiers/91): Repeat clinical diagnostic laboratory test
- [Modifier GA](/modifiers/ga): Waiver of liability statement issued as required by payer policy
- [Modifier KX](/modifiers/kx): Requirements specified in the medical policy have been met
- [Modifier XS](/modifiers/xs): Separate structure — a service that is distinct because it was performed on a separate organ or structure
- [Modifier XE](/modifiers/xe): Separate encounter — a service that is distinct because it occurred during a separate encounter
- [Modifier XP](/modifiers/xp): Separate practitioner — a service that is distinct because it was performed by a different practitioner
- [Modifier XU](/modifiers/xu): Unusual non-overlapping service — a service that is distinct because it does not overlap the usual components of the main service
- [Modifier 77](/modifiers/77): Repeat procedure or service by another physician
- [Modifier 95](/modifiers/95): Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system
- [Modifier 22](/modifiers/22): Increased procedural services
- [Modifier 52](/modifiers/52): Reduced services
- [Modifier 53](/modifiers/53): Discontinued procedure
- [Modifier 58](/modifiers/58): Staged or related procedure or service by the same physician during the postoperative period

## Comparisons

- [In-House vs Outsourced Medical Billing](/compare/in-house-vs-outsourced-medical-billing): Should a practice keep billing in-house or outsource it?
- [Medical Billing vs Medical Coding](/compare/medical-billing-vs-medical-coding): What is the difference between medical billing and medical coding?
- [Percentage of Collections vs Flat Fee Billing](/compare/percentage-of-collections-vs-flat-fee-billing): Should a billing company charge a percentage of collections or a flat fee?
- [Offshore vs Domestic Medical Billing](/compare/offshore-vs-domestic-medical-billing): Is offshore medical billing safe, and how does it compare to domestic?
- [Medical Billing Software vs a Billing Service](/compare/billing-software-vs-billing-service): Do I need better billing software or a billing service?
- [Denial Management vs Denial Prevention](/compare/denial-management-vs-denial-prevention): Is it better to prevent denials or get better at appealing them?
- [athenahealth RCM vs an Outsourced Billing Service](/compare/athenahealth-vs-outsourced-billing-service): Should billing come from the EHR vendor or from an independent billing company?
- [Tebra vs an Outsourced Billing Service](/compare/tebra-vs-outsourced-billing-service): Is an all-in-one small-practice platform or a dedicated billing service better for collections?
- [AdvancedMD RCM vs an Outsourced Billing Service](/compare/advancedmd-vs-outsourced-billing-service): Should revenue cycle come bundled with the practice management suite or be bought separately?
- [CareCloud RCM vs an Outsourced Billing Service](/compare/carecloud-vs-outsourced-billing-service): Is platform-attached revenue cycle or a standalone billing service the better fit?

## Services

- [Medical Billing & Coding](/services/medical-billing): Complete billing and coding built to maximize reimbursement and reduce denials.
- [Medical Coding](/services/medical-coding): Precision ICD-10, CPT and HCPCS coding by certified coders.
- [Revenue Cycle Management](/services/revenue-cycle-management): End-to-end financial operations from patient registration to final payment.
- [Claims Management](/services/claims-management): Advanced scrubbing, real-time tracking and data-driven submission strategy.
- [Denial Management](/services/denial-management): Root-cause analysis, strategic appeals, and prevention that compounds.
- [AR Management](/services/ar-management): Systematic follow-up that turns aging balances into collected revenue.
- [Eligibility Verification](/services/eligibility-verification): Real-time coverage checks that stop denials before they are created.
- [Prior Authorization](/services/prior-authorization): Authorization requests, tracking and appeals handled end to end.
- [Provider Credentialing](/services/credentialing): Enrollment with every major network, tracked to completion.
- [Patient Collections](/services/patient-collections): Compassionate collections that improve recovery without damaging trust.
- [Patient Support](/services/patient-support): Professional billing support that frees your front desk.
- [Practice Analytics](/services/practice-analytics): Live dashboards, benchmarking, and analysis you can act on.

## Specialties

Each page carries the CPT codes that specialty actually bills, its
characteristic denial reasons, payer-mix notes and specialty benchmarks.

- [Cardiology](/specialties/cardiology): Interventional, diagnostic and device monitoring billing.
- [Dermatology](/specialties/dermatology): Medical versus cosmetic, lesion coding, and Mohs billing.
- [Orthopedics](/specialties/orthopedics): Surgical global periods, arthroscopy bundling and DME.
- [Mental & Behavioral Health](/specialties/mental-health): Time-based session coding, panels and credentialing.
- [OB-GYN](/specialties/obgyn): Obstetric global packages, gynecologic surgery and screening.
- [Pediatrics](/specialties/pediatrics): Well-child visits, immunizations and developmental screening.
- [Family Medicine](/specialties/family-medicine): Preventive care, chronic care management and E/M accuracy.
- [Internal Medicine](/specialties/internal-medicine): Complex chronic disease, care management and risk adjustment.
- [Anesthesia](/specialties/anesthesia): Base plus time units, medical direction and concurrency.
- [Pain Management](/specialties/pain-management): Injection procedures, frequency limits and prior authorization.
- [Physical Therapy](/specialties/physical-therapy): Timed units, the 8-minute rule and authorization tracking.
- [Gastroenterology](/specialties/gastroenterology): Screening versus diagnostic, endoscopy and anesthesia coordination.
- [Radiology](/specialties/radiology): Technical/professional splits, contrast studies and imaging authorization.
- [Urgent Care](/specialties/urgent-care): Walk-in E/M, in-house procedures and real-time eligibility.
- [Neurology](/specialties/neurology): Diagnostic testing, infusion therapy and complex E/M.
- [Oncology](/specialties/oncology): Buy-and-bill drugs, infusion hierarchy and treatment authorization.
- [Ophthalmology](/specialties/ophthalmology): Medical versus vision routing, injections and surgical globals.
- [Podiatry](/specialties/podiatry): Routine foot care rules, Q modifiers and diabetic supplies.
- [Chiropractic](/specialties/chiropractic): Manipulation coding, the AT modifier and maintenance-care rules.
- [Urology](/specialties/urology): Cystoscopy bundling, in-office procedures and hormone therapy.
- [ENT & Otolaryngology](/specialties/ent): Endoscopy, audiology coverage and allergy immunotherapy.
- [Nephrology](/specialties/nephrology): ESRD monthly capitation, vascular access and CKD management.
- [General Surgery](/specialties/general-surgery): Global periods, modifier discipline and assistant surgeon billing.
- [Wound Care](/specialties/wound-care): Debridement depth, skin substitutes and serial documentation.
- [Durable Medical Equipment](/specialties/dme): Written orders, face-to-face rules and modifier discipline.

## Locations

Each state page carries the Medicaid program name and delivery model, the
Medicare Administrative Contractor and jurisdiction, regional commercial
payers, and Medicaid expansion status.

- [Alabama](/locations/alabama): Alabama Medicaid, Palmetto GBA (JJ)
- [Alaska](/locations/alaska): Alaska Medical Assistance, Noridian Healthcare Solutions (JF)
- [Arizona](/locations/arizona): AHCCCS, Noridian Healthcare Solutions (JF)
- [Arkansas](/locations/arkansas): ARHOME, Novitas Solutions (JH)
- [California](/locations/california): Medi-Cal, Noridian Healthcare Solutions (JE)
- [Colorado](/locations/colorado): Health First Colorado, Novitas Solutions (JH)
- [Connecticut](/locations/connecticut): HUSKY Health, National Government Services (JK)
- [Delaware](/locations/delaware): Diamond State Health Plan, Novitas Solutions (JL)
- [Florida](/locations/florida): Statewide Medicaid Managed Care, First Coast Service Options (JN)
- [Georgia](/locations/georgia): Georgia Families, Palmetto GBA (JJ)
- [Hawaii](/locations/hawaii): Med-QUEST, Noridian Healthcare Solutions (JE)
- [Idaho](/locations/idaho): Idaho Medicaid, Noridian Healthcare Solutions (JF)
- [Illinois](/locations/illinois): HealthChoice Illinois, National Government Services (J6)
- [Indiana](/locations/indiana): Healthy Indiana Plan, Wisconsin Physicians Service (J8)
- [Iowa](/locations/iowa): IA Health Link, Wisconsin Physicians Service (J5)
- [Kansas](/locations/kansas): KanCare, Wisconsin Physicians Service (J5)
- [Kentucky](/locations/kentucky): Kentucky Medicaid, CGS Administrators (J15)
- [Louisiana](/locations/louisiana): Healthy Louisiana, Novitas Solutions (JH)
- [Maine](/locations/maine): MaineCare, National Government Services (JK)
- [Maryland](/locations/maryland): Maryland HealthChoice, Novitas Solutions (JL)
- [Massachusetts](/locations/massachusetts): MassHealth, National Government Services (JK)
- [Michigan](/locations/michigan): Healthy Michigan Plan, Wisconsin Physicians Service (J8)
- [Minnesota](/locations/minnesota): Minnesota Medical Assistance, National Government Services (J6)
- [Mississippi](/locations/mississippi): MississippiCAN, Novitas Solutions (JH)
- [Missouri](/locations/missouri): MO HealthNet, Wisconsin Physicians Service (J5)
- [Montana](/locations/montana): Montana Medicaid, Noridian Healthcare Solutions (JF)
- [Nebraska](/locations/nebraska): Heritage Health, Wisconsin Physicians Service (J5)
- [Nevada](/locations/nevada): Nevada Medicaid, Noridian Healthcare Solutions (JE)
- [New Hampshire](/locations/new-hampshire): NH Medicaid Care Management, National Government Services (JK)
- [New Jersey](/locations/new-jersey): NJ FamilyCare, Novitas Solutions (JL)
- [New Mexico](/locations/new-mexico): Turquoise Care, Novitas Solutions (JH)
- [New York](/locations/new-york): New York Medicaid, National Government Services (JK)
- [North Carolina](/locations/north-carolina): NC Medicaid Managed Care, Palmetto GBA (JM)
- [North Dakota](/locations/north-dakota): North Dakota Medicaid, Noridian Healthcare Solutions (JF)
- [Ohio](/locations/ohio): Ohio Medicaid, CGS Administrators (J15)
- [Oklahoma](/locations/oklahoma): SoonerCare, Novitas Solutions (JH)
- [Oregon](/locations/oregon): Oregon Health Plan, Noridian Healthcare Solutions (JF)
- [Pennsylvania](/locations/pennsylvania): HealthChoices, Novitas Solutions (JL)
- [Rhode Island](/locations/rhode-island): RIte Care, National Government Services (JK)
- [South Carolina](/locations/south-carolina): Healthy Connections, Palmetto GBA (JM)
- [South Dakota](/locations/south-dakota): South Dakota Medicaid, Noridian Healthcare Solutions (JF)
- [Tennessee](/locations/tennessee): TennCare, Palmetto GBA (JJ)
- [Texas](/locations/texas): Texas Medicaid and STAR, Novitas Solutions (JH)
- [Utah](/locations/utah): Utah Medicaid, Noridian Healthcare Solutions (JF)
- [Vermont](/locations/vermont): Green Mountain Care, National Government Services (JK)
- [Virginia](/locations/virginia): Cardinal Care, Palmetto GBA (JM)
- [Washington](/locations/washington): Apple Health, Noridian Healthcare Solutions (JF)
- [West Virginia](/locations/west-virginia): Mountain Health Trust, Palmetto GBA (JM)
- [Wisconsin](/locations/wisconsin): BadgerCare Plus, National Government Services (J6)
- [Wyoming](/locations/wyoming): Wyoming Medicaid, Noridian Healthcare Solutions (JF)

## Articles

- [LCDs and NCDs: how Medicare actually decides what is covered](/blog/lcds-ncds-and-how-coverage-is-decided): Coverage is not one rule. A national determination binds everyone; a local one binds only its jurisdiction — and most medical necessity denials trace to the second kind.
- [Medicare Part B billing: your MAC decides more than the fee schedule](/blog/medicare-part-b-billing-and-your-mac): Medicare is national, but the contractor that adjudicates your claims is regional — and that contractor sets coverage policy, review targets and the answer you get on appeal.
- [Medicaid billing: why the same claim behaves differently in every state](/blog/medicaid-billing-state-programs-and-managed-care): Medicaid is fifty programs, not one payer. What that changes about eligibility, filing deadlines, authorization and who actually adjudicates your claim.
- [Nephrology billing: monthly capitation for dialysis and what sits outside it](/blog/nephrology-dialysis-monthly-capitation-billing): Dialysis management is paid monthly rather than per visit, and the code depends on the patient's age and how many times they were seen. Almost everything else nephrology does is billed normally.
- [Chiropractic billing: active treatment, the AT modifier and maintenance care](/blog/chiropractic-billing-at-modifier-and-maintenance): Medicare covers exactly one chiropractic service, and only while the patient is improving. Everything else in the practice is the patient's own cost — which makes the conversation as important as the coding.
- [Wound care billing: debridement by depth and area, and the measurements that prove it](/blog/wound-care-debridement-depth-and-documentation): Debridement codes are selected by the deepest tissue removed and the surface area treated. Both are numbers, and a note without them selects the lowest-paying code by default.
- [DME billing: written orders, medical necessity files and the KX modifier](/blog/dme-billing-orders-documentation-and-kx): Durable medical equipment is denied on paperwork more than on eligibility. The equipment is usually appropriate; the file supporting it usually is not complete before delivery.
- [Pediatric billing: vaccine administration units and same-day sick visits](/blog/pediatric-billing-vaccines-and-well-child-visits): Pediatrics bills low-value encounters at high volume, which means a small per-visit error compounds faster here than anywhere else in medicine.
- [Internal medicine billing: wellness visits, chronic care and E/M selection](/blog/internal-medicine-wellness-visits-and-chronic-care): Medicare does not cover an annual physical. It covers something adjacent with a different name, different content and different codes — and the confusion between them is expensive.
- [Neurology billing: nerve conduction study counts, EEG and botulinum policy](/blog/neurology-billing-nerve-studies-and-eeg): Neurology's diagnostic testing is billed by counting studies, and payers audit those counts more closely than almost anything else in outpatient medicine.
- [Ophthalmology billing: eye codes versus E/M and medical versus vision plans](/blog/ophthalmology-eye-codes-and-plan-routing): Eye care is the only specialty with a parallel code set to evaluation and management, and a parallel insurance system to route claims through. Both choices are made per visit.
- [Podiatry billing: the routine foot care exclusion and Q modifiers](/blog/podiatry-routine-foot-care-coverage): Medicare excludes routine foot care by statute, then covers it anyway when specific systemic findings are documented. Nearly all podiatry revenue turns on that exception.
- [OB-GYN billing: the global obstetric package and what falls outside it](/blog/obgyn-global-obstetric-package-billing): One code covers nine months of care. Knowing precisely what it does not cover is where obstetric practices find the revenue they are already earning.
- [Urology billing: cystoscopy bundling, urodynamics components and PSA coverage](/blog/urology-cystoscopy-and-urodynamics-billing): Urology runs a diagnostic procedure that is included in almost every therapeutic one, and a test suite billed in components that must each be separately documented.
- [ENT billing: endoscopy bundling, audiology coverage and allergy dose units](/blog/ent-billing-endoscopy-audiology-allergy): An otolaryngology practice runs four different billing models under one roof. Most ENT revenue loss happens at the seams between them.
- [Gastroenterology billing: screening versus diagnostic colonoscopy](/blog/gastroenterology-screening-vs-diagnostic-colonoscopy): One distinction drives most gastroenterology denials and nearly every patient billing complaint: whether the colonoscopy was screening or diagnostic, and what happens when it starts as one and becomes the other.
- [Radiology billing: component splits, orders and medical necessity denials](/blog/radiology-billing-professional-technical-component): Radiology is the specialty where you bill for a patient you never met, using an order someone else wrote. That structure produces a denial profile unlike any other specialty.
- [Dermatology billing: lesion measurement, pathology timing and cosmetic denials](/blog/dermatology-lesion-billing-and-medical-necessity): Dermatology codes are selected on a measurement taken before the excision and a pathology result that arrives after it. That sequence causes most of the specialty's revenue loss.
- [Pain management billing: frequency limits, imaging guidance and diagnostic blocks](/blog/pain-management-injection-billing): Interventional pain is governed by payer medical policy more tightly than almost any specialty — and the policy is published, which makes most denials predictable.
- [Oncology billing: drug units, wastage and the infusion hierarchy](/blog/oncology-drug-units-and-infusion-billing): A unit miscalculation on a biologic can exceed the value of an entire clinic day, in either direction — and it rarely shows up as a denial.
- [Anesthesia billing: base units, time units and medical direction](/blog/anesthesia-billing-units-and-medical-direction): Anesthesia is the only specialty where payment is calculated rather than looked up — and every input to that calculation is a place revenue leaks.
- [General surgery billing: assistants, co-surgeons and converted procedures](/blog/general-surgery-assistant-and-team-billing): When more than one surgeon is involved, or the procedure changes mid-case, the modifier decides whether the work gets paid at all.
- [Urgent care billing: S-codes, modifier 25 and the walk-in eligibility problem](/blog/urgent-care-billing-s-codes-and-modifier-25): No scheduled appointment means no window to verify coverage — which puts urgent care at the sharp end of the largest denial category in healthcare.
- [Cardiology billing: component splits, global periods and monitoring intervals](/blog/cardiology-billing-component-denials): Three denial patterns account for most cardiology write-offs, and all three come from billing correct work under the wrong structure.
- [Family medicine billing: E/M levels, wellness visits and care management](/blog/family-medicine-em-and-preventive-denials): Primary care loses more revenue to undercoding than to denials, and the biggest single confusion is between a Medicare wellness visit and a physical.
- [Why behavioral health claims deny, and what fixes them](/blog/behavioral-health-billing-denials): Time-based session codes, carved-out payers and visit limits make behavioral health the specialty where correct clinical work most often bills incorrectly.
- [Surgical global periods and why orthopedic claims deny](/blog/orthopedic-billing-global-periods): Global periods, modifier selection and NCCI bundling make orthopedics the specialty where correct surgery is most often billed incorrectly — usually downward.
- [The 8-minute rule and physical therapy billing units](/blog/physical-therapy-billing-units): Timed codes, untimed codes and the unit arithmetic between them. Where therapy practices lose revenue that was clinically earned and correctly delivered.
- [How much does medical billing cost?](/blog/how-much-does-medical-billing-cost): Outsourced billing runs 4–8% of collections. In-house looks cheaper until you cost the whole function rather than one salary. Here is the comparison with the parts most calculations leave out.
- [Prior authorization denials: why 88% go unappealed](/blog/prior-authorization-denials-appeal): Four out of five appealed Medicare Advantage prior-auth denials are overturned. Almost nobody appeals them. The gap is capacity, not merit — and it is measurable.
- [Top reasons medical claims get denied](/blog/top-reasons-medical-claims-get-denied): Registration and eligibility errors cause more denials than coding does. Here is what the data actually shows, and what to fix first.
- [How to improve your clean claim rate](/blog/how-to-improve-clean-claim-rate): First-pass acceptance is the cheapest revenue improvement available. Here is what moves it, in order of impact.
- [What is revenue cycle management?](/blog/what-is-revenue-cycle-management): A plain explanation of RCM, how it differs from medical billing, and which metrics actually indicate whether yours is working.
- [Credentialing mistakes that delay payments](/blog/credentialing-mistakes-that-delay-payments): A provider who cannot bill still costs you a salary. The five credentialing errors that create the longest revenue gaps.
- [How practices lose revenue through AR aging](/blog/how-practices-lose-revenue-through-ar-aging): Accounts receivable decay with age. Past the filing deadline they collect at zero. Here is how to work AR by recoverability.
- [Eligibility verification best practices](/blog/eligibility-verification-best-practices): The cheapest denial prevention available, and the one most practices perform once instead of continuously.
- [Understanding annual medical coding updates](/blog/understanding-medical-coding-updates): ICD-10 changes October 1, CPT changes January 1. Claims are validated against the service date, not the submission date.

## Glossary

Definitions are reproduced in full rather than linked bare, because a
definition is short enough to be useful in an index and is the thing most
often quoted. Each is written to stand alone at 40-60 words.

- [Revenue Cycle Management](/glossary/revenue-cycle-management): Revenue cycle management is the end-to-end financial process a healthcare practice runs from the moment a patient schedules an appointment until the balance for that visit is fully paid. It covers eligibility verification, coding, claim submission, payer follow-up, denial appeals, patient billing and reporting.
- [Clean Claim](/glossary/clean-claim): A clean claim is a claim that passes payer adjudication and is paid on first submission, without rejection, denial or a request for additional information. Clean claim rate — the percentage of claims meeting that standard — is the most direct measure of whether a billing operation is working.
- [Claim Scrubbing](/glossary/claim-scrubbing): Claim scrubbing is the automated review of a claim before submission, checking it against payer rules, code edits and formatting requirements to catch errors that would cause a rejection or denial. It runs after coding and before transmission, and it is the cheapest possible point of correction.
- [Clearinghouse](/glossary/clearinghouse): A clearinghouse is an intermediary that receives claims from providers, validates and reformats them into each payer's required electronic standard, and routes them onward. It also returns acknowledgements, rejections and electronic remittance advice, acting as the single connection point to hundreds of payers.
- [EDI 837](/glossary/edi-837): The EDI 837 is the HIPAA-mandated electronic format for submitting healthcare claims. The 837P variant carries professional claims, 837I carries institutional claims, and 837D carries dental. It is the electronic equivalent of a CMS-1500 or UB-04 paper form.
- [ERA](/glossary/era): An electronic remittance advice, transmitted as an X12 835 file, is the payer's electronic explanation of how a claim was adjudicated. It reports what was allowed, what was paid, what was adjusted and why — using CARC and RARC codes — and it drives automated payment posting.
- [CMS-1500](/glossary/cms-1500): The CMS-1500 is the standard paper claim form used by physicians and non-institutional providers to bill Medicare, Medicaid and most commercial payers. It is maintained by the National Uniform Claim Committee, and its electronic equivalent is the EDI 837P transaction.
- [Charge Capture](/glossary/charge-capture): Charge capture is the process of recording every billable service a provider delivered so it reaches a claim. Services documented in the chart but never converted into a charge are revenue lost permanently — no denial appears, no report flags it, and nothing prompts anyone to look.
- [Superbill](/glossary/superbill): A superbill is an itemized record of the services a provider delivered during a visit, listing diagnosis and procedure codes, provider details and charges. It is not a claim: it is the source document a biller converts into a claim, or that a patient submits to seek out-of-network reimbursement.
- [Payment Posting](/glossary/payment-posting): Payment posting is the recording of payer and patient payments against the correct claims and service lines, including contractual adjustments, write-offs and patient responsibility. Done well it reconciles to the bank deposit; done poorly it corrupts every AR and denial report downstream.
- [CPT Code](/glossary/cpt-code): A CPT code is a five-character code maintained by the American Medical Association that identifies the procedure or service a provider performed. CPT answers what was done; ICD-10-CM answers why. Together they establish medical necessity, and a mismatch between them is a leading denial cause.
- [ICD-10-CM](/glossary/icd-10-cm): ICD-10-CM is the diagnosis code set used in the United States to report the clinical reason for a service. Codes run three to seven characters, and the later characters carry specificity — laterality, encounter type, episode — that payers increasingly require before they will accept medical necessity.
- [HCPCS](/glossary/hcpcs): HCPCS Level II is a CMS-maintained code set covering products, supplies and services not included in CPT — durable medical equipment, prosthetics, ambulance services, and drugs administered in a clinical setting. Level I of HCPCS is CPT itself.
- [Modifier](/glossary/modifier): A modifier is a two-character suffix appended to a CPT or HCPCS code that alters its meaning without changing the code itself — signalling that a service was distinct, bilateral, repeated, reduced or performed by a specific provider role. Modifiers are how correct coding survives contact with bundling edits.
- [E/M Coding](/glossary/e-m-coding): Evaluation and management coding assigns a level of service to a patient encounter based on either medical decision making or total time spent on the date of the encounter. Since the 2021 guideline revision, history and exam no longer determine the level for office visits.
- [NCCI Edits](/glossary/ncci-edits): National Correct Coding Initiative edits are CMS-published rules preventing improper code pairings. Procedure-to-procedure edits stop two codes being billed together when one is a component of the other; medically unlikely edits cap the units of a code reportable for one patient on one day.
- [Upcoding](/glossary/upcoding): Upcoding is billing a higher-paying code than the documented service supports. It is a False Claims Act exposure regardless of intent, and it is detected statistically — payers profile a provider's code distribution against peers in the same specialty, so a skewed pattern surfaces without any single claim being reviewed.
- [Undercoding](/glossary/undercoding): Undercoding is billing a lower-level or less specific code than the documentation supports. It produces no denials, triggers no alerts and appears nowhere in a standard revenue report — which makes it the least visible and most persistent form of revenue leakage in a physician practice.
- [Denial](/glossary/denial): A denial is a claim the payer adjudicated and refused to pay. It differs from a rejection, which never entered adjudication. That distinction determines your remedy: a rejected claim is corrected and resubmitted, while a denied claim must be appealed within the payer's deadline.
- [Rejection](/glossary/rejection): A rejection is a claim stopped before adjudication — by the clearinghouse or the payer's intake system — for a format, data or eligibility error. Because it never entered adjudication, it carries no appeal rights and does not appear in payer claim status. It must be corrected and resubmitted.
- [CARC](/glossary/carc): A claim adjustment reason code explains why a payer adjusted or denied a payment. Maintained by X12, each CARC carries a group code — CO for contractual obligation, PR for patient responsibility, OA for other adjustment — which determines whether the balance may be billed to the patient.
- [RARC](/glossary/rarc): A remittance advice remark code supplements a CARC with the specific reason behind an adjustment. Where a CARC says information is missing, the RARC says which information. Reading the RARC is usually what determines whether a denial is correctable, appealable, or genuinely final.
- [Appeal](/glossary/appeal): An appeal is a formal request that a payer reconsider a denied claim, supported by documentation addressing the stated denial reason. Commercial payers typically allow 90 to 180 days from the remittance date; Medicare provides five escalating levels beginning with redetermination within 120 days.
- [Timely Filing](/glossary/timely-filing): Timely filing is the deadline by which a payer must receive a claim. Limits commonly range from 90 days to one year from the date of service, vary by payer and contract, and are shorter for secondary claims. A claim denied for timely filing is generally unappealable and unbillable to the patient.
- [Medical Necessity](/glossary/medical-necessity): Medical necessity is a payer's determination that a service was appropriate for the patient's condition under its coverage policy. It is established by the pairing of diagnosis and procedure codes and supported by the documentation — which means a medically necessary service can still be denied if the coding does not demonstrate it.
- [Prior Authorization](/glossary/prior-authorization): Prior authorization is a payer requirement that a service be approved before it is delivered. Without it, the claim is denied regardless of medical necessity, and in most contracts the balance cannot be billed to the patient — the practice absorbs it entirely.
- [Days in AR](/glossary/days-in-ar): Days in accounts receivable measures the average time between billing a service and collecting payment. It is calculated as total accounts receivable divided by average daily charges. It is the single best summary indicator of revenue cycle health, because every upstream failure eventually shows up in it.
- [Denial Rate](/glossary/denial-rate): Denial rate is the percentage of submitted claims a payer denies, usually measured on first submission. MGMA data puts single-specialty physician practices at roughly 8%; Kodiak Solutions reports 11.81% for hospitals and health systems in 2024. Above 10% is where practices generally start losing material revenue.
- [Net Collection Rate](/glossary/net-collection-rate): Net collection rate is payments received divided by the amount you were contractually entitled to collect, after removing contractual adjustments. It answers the question gross collection rate cannot: of the money you actually had a right to, how much did you get?
- [Contractual Adjustment](/glossary/contractual-adjustment): A contractual adjustment is the difference between a provider's billed charge and the contracted allowed amount with that payer. It is not a loss and not collectible from the patient — it is the discount agreed to in the contract, and it must be recorded separately from write-offs.
- [Underpayment](/glossary/underpayment): An underpayment is a claim paid below the contracted allowed amount. Unlike a denial it produces no alert, posts cleanly, and closes the claim — which is why systematic underpayment can run for years without anyone noticing. Detection requires comparing every payment against a loaded fee schedule.
- [Allowed Amount](/glossary/allowed-amount): The allowed amount is the maximum a payer recognizes for a covered service under its contract with the provider. It sets the ceiling on total payment — payer portion plus patient responsibility — and the difference between billed charge and allowed amount becomes a contractual adjustment.
- [Eligibility Verification](/glossary/eligibility-verification): Eligibility verification confirms a patient's active coverage, benefits, deductible status, copay, coinsurance and authorization requirements before the service is delivered. It runs electronically through the X12 270 inquiry and 271 response, and it prevents the largest single category of denials.
- [Coordination of Benefits](/glossary/coordination-of-benefits): Coordination of benefits determines which payer is primary when a patient has more than one plan, and in what order the others pay. Billing the wrong payer first produces a denial that cannot be fixed by resubmission alone — the payers' own COB records must be corrected first.
- [Patient Responsibility](/glossary/patient-responsibility): Patient responsibility is the portion of an allowed amount the patient owes: copay, coinsurance, deductible and non-covered charges. It is identified on the remittance by PR group codes, and it has become materially harder to collect as high-deductible plans have grown.
- [Out-of-Network](/glossary/out-of-network): Out-of-network describes a provider with no contract with a patient's payer. Without a contracted allowed amount the payer applies its own reimbursement methodology, patient cost-sharing is higher, and federal No Surprises Act protections restrict what may be balance-billed in emergency and certain facility-based situations.
- [Credentialing](/glossary/credentialing): Credentialing is the verification of a provider's qualifications by a payer, and enrollment is the resulting contract that permits billing under that plan. The process commonly takes 90 to 180 days, and claims for services delivered before the effective date are generally not payable.
- [NPI](/glossary/npi): A National Provider Identifier is the 10-digit identifier required on all HIPAA standard transactions. Type 1 identifies an individual provider; Type 2 identifies an organization. Both usually appear on a claim — the rendering provider as Type 1, the billing entity as Type 2.
- [HIPAA](/glossary/hipaa): HIPAA is the federal law governing the privacy and security of protected health information. For billing it establishes three obligations: the standard electronic transaction formats, the Privacy Rule limiting use and disclosure of PHI, and the Security Rule requiring safeguards for electronic PHI.
- [Business Associate Agreement](/glossary/business-associate-agreement): A Business Associate Agreement is the HIPAA-required contract between a covered entity and a vendor handling protected health information on its behalf. It defines permitted uses, mandates safeguards, sets breach notification obligations, and governs return or destruction of PHI when the relationship ends.
- [Minimum Necessary](/glossary/minimum-necessary): The minimum necessary standard requires that uses and disclosures of protected health information be limited to the least amount needed to accomplish the purpose. It applies directly to billing operations, where the temptation to move whole charts rather than the relevant documentation is constant.

## Machine-readable endpoints

If you are a tool or agent rather than a reader, these carry the same content
without the page around it.

- [/ai/summary.json](https://vizora.co/ai/summary.json): Identity, services, specialties, states served, payers, pricing model and contact, as JSON.
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- [/.well-known/ai.txt](https://vizora.co/.well-known/ai.txt): How this content may be used and how to attribute it.

## A note on our statistics

Industry statistics on this site name their source, dataset and data year, and
link to the publisher. We deliberately exclude several figures that circulate
widely in medical billing marketing but have no verifiable primary source —
including "50-65% of denied claims are never reworked", "90% of denials are
preventable", and "$118 to rework a claim" (2016 data still quoted as current).
The excluded list and the reasoning are published at /resources/rcm-benchmarks.

If you are quoting figures from this site, please carry the attribution through.

## Contact

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