Why Box 19 Is the First Thing a Reviewer Reads When a claim lands on a payer reviewer’s desk with an unlisted procedure code in Box 24D, the reviewer does not open the attached operative report first. They read Box 19. That single field, labeled Additional Claim Information on the current version of the CMS-1500 … Read more
Why Unlisted Code Claims Get Denied More Than Any Other Code Type Unlisted CPT code claims fail at a higher rate than any other claim category in medical billing. The reason is structural. Every other claim type runs through automated adjudication using predefined fee schedule rules, coverage policies, and bundling edits. Unlisted code claims skip … Read more
The Gap Between What Providers Document and What Payers Need Medical necessity is the single most cited reason for claim denial across every payer type in the US healthcare system. The 2025 State of Claims report from Experian Health identified insufficient documentation as a top cause of denials, with denial rates reaching between 10 and … Read more
Why Surgical Prior Authorization Failures Cost More Than Any Other Denial Type Prior authorization denials for surgical procedures are the most expensive denial category in medical billing, not because individual claims are larger than other service types, but because the downstream consequences compound quickly. A surgical claim denied for missing or invalid prior authorization typically … Read more
What a MAC Prepayment Review Actually Is A Medicare Administrative Contractor prepayment review is a formal medical record audit that occurs before Medicare pays a claim rather than after. When a claim is selected for prepayment review, payment is suspended while the MAC requests clinical documentation to verify that the service meets Medicare’s coverage, coding, … Read more
Why the 2026 OIG Work Plan Demands Immediate Attention The Office of Inspector General of the US Department of Health and Human Services publishes and continuously updates a Work Plan that identifies the programs, services, and billing patterns it intends to audit. The 2026 Work Plan is not a prediction of where enforcement might eventually … Read more