Medical Billing is as Tough as Keeping Score in Tennis-Part 2

Last week seeing Wimbledon on the television, I was inspired to write about how the complexities of medical billing can seem similar to those in scoring for tennis. If you missed part 1, I discussed the referral and authorization quagmire that often exists in the medical office, especially specialists.

Medical billing blogYou can see the post here

Like previously stated, in tennis, in life and in the world of medical billing, we are constantly faced with situations that may seem illogical or over complex without reason, but we must learn to accept them, and develop strategies to cope.

Point Two (or Thirty in Tennis)


We all hate them, we try to prevent them, but despite our best efforts, they happen.  One scenario as described by Adjustment Reason Code 97can be somewhat easily avoided.


”The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.”


This particular denial is often the result of the National Correct Coding Initiative Edits.  


This data file contains HCPCS codes in “pair groups” that indicate theprocedure listed in Column 2 is part of the more comprehensive procedure listed in Column 1.

I kind of relate this to buying a car and then also getting billed for the engine.  The engine is generally included.On occasion though, maybe there is an upgrade required to the engine, this would be a separate charge.

In medical billing, when we encounter those items that are usually included but there are extenuating circumstances we are allowed for those items indicated with a “1” in the NCCI data file  to add a “59” modifier and override the edit. 

Care must be used with this process though; the included service must be documented specifically as to why it should be considered a separate service.

How do medical billers remember what the code conflicts are and which have the potential to be overridden? 

The best way is to have an integrated claim scrubber in your medical billing software

Iridium Suite Practice Management Software contains not only all the NCCI edits, but users can request to have custom scrubber rules created that apply to the special billing situations of their practice/specialty.

Another denial often received is for duplicate of exact services, Adjustment Reason Code 18

Many times these are caused by simple data entry errors. 

Too many duplicate claim entries can cause the Accounts Receivable reports for the practice to seem inaccurate with more than the expected amount of contractual write-offs. 

The Iridium Suite scrubber will also notify users of duplicate code entries prior to submission to eliminate these types of issues.