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Specialty Billing Checklists That Eliminate Denials Before They Happen
Each checklist covers the highest-risk coding errors, modifier requirements, and documentation gaps for that specialty — the exact issues that drive 80% of denials.
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6 Specialty Billing Checklists
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🦴 Orthopedics
Orthopedic Billing Pre-Submission Checklist
Global period violations and modifier errors account for 34% of ortho denials. This checklist catches them before the claim goes out.
Global period verification (10-day vs 90-day)
Modifier 58 / 59 / 79 logic check
Bilateral procedure modifier 50 rules
+ 9 more items
✓ Orthopedic Billing Checklist
Global Period & Modifiers
Verify global period: 10-day (minor) vs 90-day (major) for each procedure
Modifier 79 applied for unrelated procedure within global period
Modifier 58 for staged/related procedure within global — not 79
Bilateral procedure: modifier 50 on single line OR submit two lines with LT/RT
Multiple Procedures & Bundling
Modifier 59 / XS / XU applied to unbundle separate anatomical site procedures
Multiple procedure reductions (modifier 51) applied and reimbursement verified
Add-on codes (+codes) are never billed without primary procedure
Implants & Supplies
Implant invoice attached for codes requiring cost documentation (e.g., 22853)
L-code or HCPCS brace/DME billed separately from procedure code — not bundled
Documentation
Operative report matches CPT code billed — no upcoding or undercoding
ICD-10 fracture code specifies laterality, episode (initial/subsequent/sequela)
Pre-auth obtained and attached if required by payer for surgical procedure
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❤️ Cardiology
Cardiology Billing Pre-Submission Checklist
Same-day E/M with procedure is the top cardiology denial. This checklist walks you through modifier 25, echo bundling, and RPM billing rules.
Modifier 25 for same-day E/M + procedure
Echo component unbundling rules
Nuclear cardiology time threshold
+ 9 more items
✓ Cardiology Billing Checklist
E/M & Same-Day Procedures
Modifier 25 on E/M when a procedure is performed the same day — separate documentation required
E/M note for same-day visit is distinct from the procedure note — not combined
Echocardiography
TTE (93306/93307/93308) — component billing only if technically and professionally split
Stress echo (93350/93351): treadmill stress code billed separately — not bundled
Doppler (93320/93321/93325) add-on codes require complete echo as primary
Nuclear & Cath
Nuclear MPI (78452): 'rest and stress' requires both components documented and billed
Cardiac cath (93458): appropriate ICD-10 indication documented — not 'chest pain, unspecified'
Remote Monitoring & Devices
RPM setup (99453) billed once at setup — not monthly
RPM monthly (99457): 20-minute minimum interactive communication documented
ILR (implantable loop recorder) interrogation: correct CPT (93299) and device ID documented
Documentation
Ordering physician documented for all diagnostic imaging and non-invasive studies
Pre-auth verified for nuclear, cath, and device procedures — reference number on claim
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🧠 Mental Health
Behavioral Health Billing Pre-Submission Checklist
Timely filing, session length documentation, and telehealth place-of-service errors drive the majority of mental health denials. This covers all three.
Session length documentation (37 vs 53 min)
Telehealth POS 02 vs 10 vs 11 rules
Interactive complexity add-on (90785)
+ 9 more items
✓ Behavioral Health Billing Checklist
Session Length & Code Selection
Psychotherapy time documented in note: 90832 (16-37 min), 90834 (38-52 min), 90837 (53+ min)
E/M + psychotherapy add-on code (90833/90836/90838) — only when medically necessary and distinct
Interactive complexity (90785) criteria met: guardian present, mandated report, or crisis intervention
Telehealth
Telehealth POS: 02 (non-home originating site), 10 (patient home) — verify payer requirement
GT modifier applied if payer requires it (Medicare vs commercial — check payer by payer)
Audio-only visits: 99441–99443 or state-specific code — not 90832–90837 unless payer allows
Substance Use & Crisis
H-codes (H0001–H2037) for substance use disorder — verify Medicaid vs commercial payer requirement
Crisis intervention (90839/90840): start/end time and crisis nature documented in note
Administrative
Authorization on file — session count tracked, not exceeded
Rendering provider NPI (Type 1) on claim — not group NPI only
Timely filing: claim submitted within payer's window (usually 90–365 days from DOS)
Diagnosis code specificity: F31.30 not appropriate when F31.31/F31.32 is documented
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🔬 Gastroenterology
Gastroenterology Billing Pre-Submission Checklist
Screening vs diagnostic colonoscopy is the most common GI billing error. This checklist ensures correct ICD-10 context, PT modifier use, and polyp coding.
Screening vs diagnostic colonoscopy ICD-10
PT modifier for screening converted to diagnostic
Polyp removal code selection rules
+ 9 more items
✓ Gastroenterology Billing Checklist
Colonoscopy — Screening vs Diagnostic
Screening colonoscopy: Z12.11 as primary ICD-10 — not symptoms or family history as primary
Screening converted to diagnostic: PT modifier on 45378/45380/45385 — not omitted
High-risk screening (Z80.0, Z83.71): payer frequency override documented — not denied as 'too soon'
Polyp Removal & Interventions
Polyp removal: 45380 (biopsy) vs 45385 (snare) vs 45384 (hot biopsy) — technique documented
Multiple polyps: each removal technique billed separately with modifier 59 or XS
Upper Endoscopy (EGD)
EGD with biopsy (43239) vs EGD alone (43235): pathology order confirms biopsy taken
Same-day upper and lower endoscopy: modifier 51 not needed — both are diagnostic, bill separately
ERCP & Complex Procedures
ERCP (43260–43278): specific intervention code — not 43260 (diagnostic) when therapeutic performed
Pre-authorization in place for ERCP — reference number documented on claim
Documentation & Coding
Bowel prep quality documented — incomplete prep with incomplete exam coded separately (45378-52)
Anesthesia: MAC anesthesia provider's claim separate from proceduralist — not bundled
ICD-10 adenoma vs polyp distinction: D12.x (adenoma) vs K63.5 (polyp) — matches pathology
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🏃 Physical Therapy
Physical Therapy Billing Pre-Submission Checklist
The 8-minute rule and KX modifier are the two most commonly missed PT billing requirements. This checklist ensures full compliance with both.
8-minute rule unit calculation per service
KX modifier for therapy cap exceptions
CQ/CO modifier for PTA services
+ 9 more items
✓ Physical Therapy Billing Checklist
8-Minute Rule & Unit Counting
Each timed procedure ≥8 minutes to bill 1 unit — exact start/end times documented per service
Remainder minutes distributed across services — no rounding up individual services
Total timed units billed do not exceed total treatment time ÷ 15 (rounded)
KX Modifier & Therapy Cap
KX modifier applied when Medicare therapy threshold exceeded — medical necessity documented in plan of care
AT modifier for maintenance therapy (skilled care required) — not routine maintenance
PTA & Provider Rules
CQ modifier on timed codes when PTA delivers >10% of service — 15% reduction applies
Supervising PT documented when PTA bills — required for CQ reduction and audit trail
Untimed Codes & Evaluation
Untimed codes (97001 eval, 97002 re-eval) billed as 1 unit regardless of time spent
97110 (therapeutic exercise) vs 97530 (therapeutic activities) — activity description matches code
Documentation & Administrative
Plan of care signed by supervising physician within 30 days — not expired
Functional limitation G-codes removed (post-2019) — not appearing on Medicare claims
ICD-10 laterality specified: M17.11 (primary OA, right knee) not M17.1 (unspecified)
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💊 Pain Management
Pain Management Billing Pre-Submission Checklist
Fluoroscopy bundling, place-of-service mismatches, and drug testing code selection are the top pain management denial drivers. All covered here.
Fluoroscopy bundling rules (77003 vs separate)
ASC vs office POS reimbursement impact
Drug testing presumptive vs definitive codes
+ 9 more items
✓ Pain Management Billing Checklist
Injections & Fluoroscopy
Epidural steroid (62321/62323): single-level code — bilateral approach does not mean 2 units
Fluoroscopy (77003) billed separately only when performed by same provider at office — not in ASC/hospital (bundled)
Facet joint injections (64490–64495): up to 3 levels on same side billable — correct level count
RFA (64633–64636): medial branch neurotomy — 2 lesions minimum per level documented
Place of Service
POS 11 (office) vs POS 24 (ASC): ASC pays facility fee separately — professional fee is reduced
POS on claim matches where procedure was actually performed — no mismatches
Drug Testing
Presumptive UDS (G0480–G0483) vs definitive (G0480 + panel codes) — method documented
Drug test frequency: monthly testing has payer-specific limits — prior auth if exceeded
Spinal Cord Stimulator
SCS trial (63650) vs permanent (63685): prior auth and psych evaluation documentation in place
Trial period outcome (≥50% pain relief) documented before permanent implant coded
Documentation
Opioid agreement and PDMP check documented when narcotics prescribed — supports medical necessity
Conservative therapy failure documented before interventional procedures — reduces peer-to-peer risk
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