The good news?

With the right Medicaid billing steps, it soon becomes routine.

Whether you run a solo office, work in a group practice, or just joined a Medicaid plan, you need a clear roadmap for the entire process.

This guide from BellMedEx gives you exactly that.

What Is Medicaid?

Medicaid is a health program jointly run by the federal and state governments in the U.S. It now covers more than 80 million people, including:

• Children
• Pregnant women
• People with disabilities
• Low-income adults
• Seniors who also receive Medicare (known as “dual eligibles”)

Why Should Healthcare Providers Treat Medicaid Patients?

Many providers worry that Medicaid pays less than private insurance or Medicare. Still, three major reasons make it worth considering:

Large patient pool – Medicaid covers a fast-growing segment of the population, especially in underserved areas.

State-level incentives – Some states offer extra perks like value-based payments or higher rates for specific specialties.

Community impact – You’re helping some of the most vulnerable people. That service brings lasting value to your community.

Here’s How to Bill Medicaid as a Provider:

Here’s a full breakdown of how to bill Medicaid successfully, from credentialing to getting reimbursed.

Step #1 – Enroll as a Medicaid Provider

You can’t send a single reimbursement claim to Medicaid until the program adds you to its roster. Therefore, your first job is getting on that list.

Think of it like joining the payroll before payday.

a). Find your state’s portal

Every state runs its own enrollment portal, and they all live on official .gov pages. A quick search for “[Your State] Medicaid provider enrollment” on Google will land you on the right link.

For example:

• In Texas, you’ll use TMHP (Texas Medicaid & Healthcare Partnership).
• In California, it’s PAVE (Provider Application and Validation for Enrollment).

If the web address doesn’t end in .gov or belong to a well-known state partner, then don’t trust it.

b). Collect the paperwork before you log in

Have these items ready before you start the Medicaid provider enrollment form:

c). Complete the online application

• Log in or create an account on your state’s portal.
• Follow each screen. Upload documents as asked.

If a field stumps you, most portals have a help line or live chat—so use it. You can also call the state’s Medicaid provider relations office, as that team’s entire job is guiding newbies like you through enrollment.

d). Let the state verify you

After you click Submit, the state reviews your file. This “Medicaid credentialing” step checks licenses and other data.

• Time frame is usually between 30 to 90 days.
• Faster for solo providers.
• Slower if you enroll a new group practice.

Once approved, you’re ready to send Medicaid claims and get paid as a healthcare provider.

Step #2 – Verify Patient Eligibility Before Each Visit

Eligibility verification simply means you confirm, ahead of time, that Medicaid still covers your patient and the service you plan to provide. A quick check spares you from most “patient not eligible” denials.

a). First, pick the method that fits your day:

• State Medicaid portal: Log in, type the patient’s Medicaid ID or birth date, and you get an instant “yes” or “no.”
• EHR or clearinghouse tool: Many systems ping Medicaid in real time. If coverage has lapsed, you’ll see a pop-up before the patient arrives.
• Medicaid helpline: A phone call takes longer, yet it helps when the portal is down or the data looks odd.

b). When you run the check, look for four things:

1. Confirm active coverage for today. Benefits can end quickly if a patient’s income changes or renewal paperwork is delayed.
2. Review service limits. Office visits are usually covered in most states, but extras—such as dental, vision, or chiropractic care—may have caps or require prior approval.
3. Check for a managed care plan. Many Medicaid members belong to an MCO. If you see “Molina,” “UnitedHealthcare Community Plan,” or another HMO name, send the bill to that plan—not directly to the state.
4. Look for other insurance. Third-party liability (TPL) means the patient has private insurance too. Medicaid pays last, so you must bill the other plan first, even if it only covers part of the charge.

Step #3 – Confirm That Medicaid Covers the Service

You have your Medicaid ID. You’ve checked the patient’s eligibility. One last check keeps your claim safe: make sure the service itself is on your state’s covered list.

When we say “make sure the service is on your state’s covered list,” we mean this: look up the exact CPT or HCPCS code for the visit, test, or procedure you plan to bill. If that code isn’t shown as covered in your state’s Medicaid fee schedule—or if it needs prior approval—you risk a denial.

Here’s how to see what Medicaid will pay?

a). Open your state’s fee schedule

Search for “Your State Medicaid fee schedule 2025.” Look for a PDF or spreadsheet on a .gov site.

b). Scan the CPT or HCPCS codes you plan to use

The schedule shows:

• Whether the code is covered
• The dollar amount Medicaid pays
• Any limits, such as age caps or visit counts
• Whether prior authorization is required

Example: North Carolina allows up to 30 physical therapy visits a year. Another state might allow only 15—or none, unless the patient is under 21.

c). Check plan bulletins for updates

States post monthly or quarterly alerts. A code that paid last year may need approval today.

d). Call the authorization desk when in doubt

A five-minute call beats a denied claim.

Step #4 – Secure Prior Authorization When It Counts

You have the patient’s Medicaid card on file, you know the service is on the covered list, and you’re ready to book the test.

Great…

but hold on a moment!

Some services need prior authorization (PA) before you provide them. Getting that green light is the difference between a paid claim and a painful write-off.

➜ Spot the usual PA suspects

As a rule of thumb, if a service is pricey, ongoing, or ordered by a specialist, plan on requesting a PA:

• High-cost imaging: MRI, CT, PET
• Elective surgeries: tonsillectomy, joint replacement, bariatric procedures
• Therapy past routine limits: mental-health counseling, speech, PT, OT
• Durable medical equipment (DME): power wheelchairs, hospital beds
• Ongoing home-health or skilled-nursing visits

Quick example:

Your patient with chronic knee pain clearly needs an MRI. You open the Medicaid HMO’s PA list and, sure enough, the scan needs approval. Rather than gamble on reimbursement, you pause, submit the request, and wait for the go-ahead.

➜ A simple roadmap for requesting PA

a). Choose the right portal

Every state—or Medicaid HMO—runs its own PA system. Some accept secure online forms; others still rely on fax. Therefore, you need to pick the path the healthcare payer prefers.

• Fill in the nuts and bolts
• CPT or HCPCS code for the service
• ICD-10 code that backs up the medical need
• Provider and facility info
• Target date of service

b). Attach proof of need

Your clinical notes, past imaging, lab results, or a referring specialist’s letter strengthen the request. Think of this bundle as answering the question, “Why does this patient need this service right now?”

c). Send, then track

Most plans give a decision within a few business days, sometimes sooner if you flag the case as urgent. Log the submission date and reference number so no one has to guess where the request stands.

d). After you hear back

• Approved. You’re free to schedule the service. Save the approval letter or confirmation number in the chart and billing file.
• Denied. Read the reason line by line. Many denials stem from missing paperwork or the wrong diagnosis code, both fixable on appeal.
• Need more info. Plans may ask for clearer notes or an extra test result. Provide what they need and resubmit; no need to start from scratch.

Step #5 – Submit Your Medicaid Claim

You have checked the patient’s coverage, confirmed the service is allowed, and grabbed any prior approval you need. Nice work. Now let’s make sure you actually get paid.

a). Pick the right claim form

• CMS-1500. Use this for office visits, shots, labs, or any other professional service.
• UB-04. Use this when you bill as a facility—hospital stays, outpatient surgery, skilled-nursing care.

Even if you hit “submit” inside your EHR, these forms sit behind the scenes. The software fills them in for you.

b). Drop in the correct codes

• ICD-10 tells Medicaid why you treated the patient.
• CPT or HCPCS show what you did.
• Modifiers add detail. For a flu shot given during a check-up, list:
  • 99213 – office visit
  • 90686 – flu vaccine
  • 90471 – vaccine administration
  • -25 on 99213 to prove the visit was separate from the shot.

c). Add a Place-of-Service (POS) code

This code shows where the care happened. A few you’ll use often:

• 11 – office
• 22 – outpatient hospital
• 12 – home
• 31 – skilled-nursing facility

Check this code twice. A wrong POS is a top reason claims bounce back.

d). List the right NPI numbers

• The rendering provider NPI must match the person who gave the care and must match the NPI on file with Medicaid.
• If you bill as a group, add the group NPI too.

e). Choose how to send the claim

• Through your EHR or practice management software. Fastest. The system fills the claim and flags missing data before you hit send.
• Through a clearinghouse. Acts like a mailroom: it scrubs errors, then routes the claim to the correct Medicaid payer.
• Direct upload to the state portal. Handy if you bill only now and then or do not have an EHR.

f). Track the claim afterward

Submitting is only half the job. Log back in a few days later and look at:

• Status – pending, paid, or denied
• Payment amount – matches your fee schedule?
• Remittance advice (RA) – explains reductions or denials

Catching a denial early often means a quick fix rather than a drawn-out appeal.

Step #6 – Track Each Claim and Match Every Dollar

Submitting the claim is only halftime. To get paid in full, you still need to watch the claim move through the system and confirm the deposit hits your account. A little follow-through here prevents big revenue leaks later.

a). How to keep eyes on your claims

➜ State Medicaid portal

Log in, search by patient or claim number, and read the status line: submitted, pending, paid, or denied.

➜ Clearinghouse dashboard

Tools like Availity or Office Ally show real-time updates—when Medicaid received the claim, whether it passed edits, and when it heads to payment.

➜ Remittance advice (RA) or EOB

This document tells you what was paid, reduced, or refused and why. Review it line by line as soon as it arrives.

b). Denials that pop up most

• Bad patient data – a wrong Medicaid ID or mistyped birth date can sink the claim.
• Coverage gap – the patient was not eligible on the service date.
• NPI or Tax ID mismatch – your claim info does not match Medicaid’s enrollment file.
• Missing prior authorization – the service needed approval, but no PA number was on the claim.

c). Reconciling payments the smart way

• Match every deposit to the specific claim in your billing system.
• Flag under-payments at once—was it a contract adjustment or an avoidable denial?
• If you need to appeal, move fast; many Medicaid programs close the window after 90 days.

Step #7 – Fix and Resubmit Denied or Rejected Claims

A denial is normal. It just means something on the claim needs a quick edit. Most states let you correct and resend—as long as you do it within their time limit (often 90–180 days from the date of service).

a). Read the denial note

Look at the Remittance Advice, EOB, or your portal. Find the short code that tells you what went wrong.

• CO-16 – missing or wrong info
• PR-49 – patient not eligible that day
• CO-96 – wrong code or modifier
• CO-109 – service not covered

b). Fix the problem

• Correct any typos in the patient name, Medicaid ID, or date of birth.
• Add the right modifier (-25, -59, etc.).
• Swap in the correct diagnosis or procedure code.
• Include the PA number if you left it off.

If the denial is about medical need, attach your notes or test results to show why the service was required.

c). Resend the claim

Use the same route you used before—portal, clearinghouse, or EHR. Mark it as a corrected claim if your state asks for that. Some states want the original claim number or a resubmission code (often “7” for a replacement claim).

d). Watch the deadline

Send the fix before the timely-filing window closes. If you are already past it, file an appeal right away and explain why you could not meet the deadline (for example, a system outage or mail delay).

e). Keep a simple denial log

Write down each denial in a list:

• Patient name and service date
• Denial reason
• Date you fixed it
• Date you resent it
• Final result

Seeing the patterns helps you prevent the same mistake next time.

But as you sit down with a strong cup of coffee, reality hits—where should you do it?

Picking the proper city isn’t just throwing a dart at a map.

It’s more like a surgical strike—you need precision, strategy, and a solid plan.

You could chase the big bucks in California, but remember, not all that glitters is gold.

Or maybe you want to go where competition is thinner, and your impact can be bigger.

Perhaps you’re looking for quality of life and career potential—a place to get peace of mind.

Where you choose to launch your orthopedic career can make or break your success.

From high salaries and booming populations to manageable overhead and supportive healthcare ecosystems, the city you call home will shape your growth, income, and work-life balance for years to come.

Today, we’re diving into the best Cities to Start an Orthopedic Practice or a job as an orthopedic surgeon.

1). San Jose, CA

Thinking about where to build your future clinic, you might wonder if San Jose is the best city for orthopedic surgeons. The paycheck here answers fast. Recent data puts average annual compensation near $702k, which is one of the highest figures in the country.

Money is only the first draw. Silicon Valley patients live online and love gadgets, so they look for robotic joint replacement, AI-based imaging reads, and app-driven rehab. You can test new tools, publish quick studies, and even pick up equity when local device start-ups need clinical partners.

Business growth feels brisk too. A large, active population with healthy insurance plans keeps appointment books full, and being near Stanford or Kaiser adds referral traffic if you focus on a niche such as sports injuries for tech workers or outpatient total joints. All of this helps San Jose stay on most “best place to practice orthopedic surgery” lists.

Now let’s keep the picture honest… that seven-figure vibe fades when you shop for a house. Zillow shows a median home price around $1.48 million. Groceries, rent, and child care follow the same pattern, leaving overall living costs roughly 80 percent above the national average. Operating overhead tells the same story: lease rates and staff salaries rise with the tech boom, while big systems already hold many prime OR blocks.

Carve out clear branding, secure solid capital, and maybe open the office a few miles south where rents drop. Break through those barriers and San Jose can still prove the best city for orthopedic surgeons who thrive on innovation.

Pros:

• Average pay tops $700k, far above national norms
• Tech-forward patients welcome robotic surgery and tele-rehab
• High insurance coverage fuels steady case volume
• Close ties to venture-backed device firms offer research and equity

Cons:

• Median home price sits near $1.48 million
• Living costs hover about 80 percent above the U.S. mean
• Fierce competition from Stanford, Kaiser, and Sutter for OR time
• Start-up practice costs run high for space, imaging, and staff

2). San Francisco

If you’re chasing prestige and professional growth, San Francisco might just be the best city for orthopedic surgeons. With an average salary of around $695,000 a year, you’d be sitting near the top of the national earnings chart.

What makes it even more compelling is the company you’d keep. You could find yourself treating patients right next to the UCSF Medical Center, a U.S. News Honor Roll hospital that consistently ranks among the top in orthopedics. Walk a few blocks and you’re in Sutter Health territory—meaning high-volume patient flow, cutting-edge research, and complex clinical cases right at your doorstep.

The patient population is just as dynamic. On any given day, you’ll see tech professionals with repetitive strain injuries, amateur athletes needing ACL reconstructions, and older adults lining up for joint replacements. Thanks to San Francisco’s high rate of private insurance coverage, your clinic stays busy, and reimbursements stay strong. This is also the kind of city where you can try robot-assisted surgeries or app-based post-op rehab and patients will embrace it.

But then comes the trade-off.

Living here is a serious financial commitment. The median home price is around $1.29 million, and daily expenses sit about 65% above the U.S. average.

Even before your first patient of the day, the city can wear you down. In 2024 alone, drivers lost 46 hours to traffic delays, cutting into clinic hours and adding stress to an already demanding schedule.

Thinking of starting your own practice? Brace yourself. Lease rates, staff salaries, and imaging overhead all scale with San Francisco’s high cost of living. Plus, major hospital systems dominate the surgical market, leaving fewer open doors for newcomers. If you want to break through, you’ll need a well-defined niche—something like outpatient total joints, sports medicine, or regenerative orthobiologics.

That said, if you carve out your space, you just might end up calling San Francisco the best place in the country to build an orthopedic career.

Pros:

• Top-tier pay near $695,000
• Access to UCSF and Sutter research and referral networks
• Well-insured, diverse patient base with complex needs
• Opportunities to lead in robotics and tele-rehab innovation

Cons:

• $1.29 million median home price and high day-to-day expenses
• Around 46 hours lost annually to traffic congestion
• Intense competition for OR time and specialty referrals
• High overhead costs for starting an independent practice

3). Milwaukee-Waukesha-West Allis, WI

If you’re thinking about the most profitable city for orthopedic surgeons that still lets you breathe financially, Milwaukee-Waukesha-West Allis deserves a serious look. The average orthopedic surgeon salary here is about $557,000 a year, giving you a strong income to work with. Even better, the cost-of-living index hovers around 88, meaning expenses are roughly 12% lower than the national average. Groceries, housing, and even clinic rent tend to cost less, which stretches your income further.

That breathing room pairs nicely with a growing healthcare scene. Systems like Froedtert Health continue expanding across southeast Wisconsin, including an $84 million new campus currently under development. More sites mean more referrals, and with Wisconsin’s aging population, you’ll find steady demand for joint replacements, sports injury repairs, and spinal procedures—exactly the kind of caseload that builds a thriving practice.

Another bonus? You won’t be elbow-to-elbow with a dozen large ortho groups. The local market is less saturated, giving you room to build a recognizable brand. Open your own clinic, partner with local marathons or schools, and word spreads fast in this community. Startup costs are also more forgiving, so you can invest in essentials like digital imaging, outpatient joint kits, or physical therapy integration without taking on overwhelming debt.

Of course, there are trade-offs. Milwaukee isn’t a research powerhouse like the coasts, so access to cutting-edge trials and devices may come a bit later. Patient volume isn’t as high as in major metros, and you’ll see fewer ultra-high-income cases. But if you focus on a clear niche—like sports medicine for student athletes or rapid-recovery joints—you can still keep your calendar full and your practice on solid ground.

Pros:

• Average salary around $557,000 with below-average living costs
• Expanding networks like Froedtert drive consistent referrals
• Fewer orthopedic competitors means easier brand visibility
• Lower startup costs for space, equipment, and staffing

Cons:

• Fewer research trials and academic ties than coastal cities
• Smaller volume of high-net-worth patients
• Harsh winters may impact recruitment or patient flow
• Travel to major ortho conferences takes longer than from cities like Chicago

4). Minneapolis–Saint Paul

Picture yourself in the Twin Cities, where you could walk the halls of the Mayo Clinic, still be home for dinner, and keep more of every paycheck. The average orthopedic salary ranges from about $460,000 to $755,000 a year, and everyday costs run about 6% below the national average. That means your income stretches farther than it would in coastal metros like San Francisco or New York.

The area’s population adds even more upside. With a well-educated, fitness-focused community, you’re likely to see steady demand for joint replacements, ACL repairs, and spine procedures. And with the Mayo Clinic ranked No. 2 in the nation for orthopedics, you’re also looking at strong opportunities for collaboration, research involvement, and clinical prestige.

If you’re thinking about opening your own clinic, the numbers work in your favor. Compared to other major cities, office rents, imaging leases, and staff wages are lower. Yet hospital systems keep expanding, and Minnesota’s aging population ensures a consistent flow of referrals. Carving out a niche in outpatient joint replacements or sports medicine for student-athletes could give you an edge, even with major players like Mayo and Allina already established.

That said, competition is no joke. The market can feel crowded with long-standing groups. You may wait for operating-room blocks, and device trials often debut in Rochester before drifting up I-35. Even so, many surgeons still call Minneapolis-St. Paul the best city for orthopedic surgeons who want top-tier medicine without West-Coast price tags.

Pros:

• Strong pay: up to $755 k while costs stay below national average
• Access to Mayo Clinic research, trials, and prestige boosts
• Health-conscious population keeps case volume steady
• Lower start-up costs make private practice realistic

Cons:

• Market feels saturated; OR time can be tight
• Big academic systems dominate complex cases
• Some cutting-edge device trials reach Rochester first
• Cold winters may deter recruits and patients looking for sunshine

5). Phoenix-Mesa-Scottsdale, AZ

Think warm desert air. Golf all year. And a steady stream of knees and hips.

That’s Phoenix.

From the moment you arrive, it feels busy—in a good way. The retiree population keeps joint-replacement demand strong, and it’s still growing. According to state projections, Arizona’s 65+ population will keep rising through at least 2026. So the work? It’s not slowing down anytime soon.

What about pay? Pretty solid. The average orthopedic salary in Phoenix is about $550,000. Meanwhile, the cost of living here is just 6% above the national average. That makes Phoenix feel affordable—especially compared to places like LA or NYC. Your paycheck goes further. Rent, mortgages, clinic space—even golf—cost less.

Jobs are everywhere. Big names like Banner and HonorHealth are hiring. At the same time, outpatient surgery centers are booming. Becker’s tracks over 600 ASCs doing total joints across the U.S., and Phoenix is one of the top spots. You can join a group, co-own a center, or launch a sports-medicine clinic without drowning in coastal-level startup costs.

But here’s the catch.

Phoenix is no secret. More surgeons move in each year. Referrals don’t flow as freely as they used to—especially around busy ASCs. If you want to stand out, you’ll need a niche. Think: same-day hips, biologic knee cartilage, or concierge rehab for the pickleball crowd.

Get that right, and Phoenix might just be your perfect orthopedic-friendly city to practice.

Pros:

• Average salary around $550k with manageable living costs
• Retiree-heavy population keeps case volume steady
• Growing ASC and hospital networks offer flexible job options
• Startup costs stay low for private practices

Cons:

• Referral competition is heating up
• ASCs may limit hospital OR availability
• Long, hot summers aren’t for everyone
• Fewer early-phase research trials compared to academic hubs

6). Detroit-Warren-Dearborn

Looking for real impact and good income? Detroit-Warren-Dearborn might surprise you.

The average orthopedic salary here is around $557,000, and living costs are close to the national average. Compared to the coasts, everything from housing to clinic space feels way more affordable.

But the real difference is the need.

Detroit still has many federally designated shortage areas. People often drive long distances just to see a specialist. If you’re an orthopedic surgeon, you’re needed the minute you show up. That makes Detroit feel like the best place to build a meaningful practice that actually helps people.

The city’s revival also works in your favor. Clinic space rents are reasonable. Hospitals are open to community partnerships. You can set up in an underserved neighborhood, host rehab events, and your name spreads fast. You build trust quickly and keep overhead low while doing it.

Still, there are trade-offs. Some patients struggle with co-pays, so not every case brings top-tier reimbursement. Device trials and premium implants usually roll out on the coasts first. And yes, winters are long and snowy, which might slow down visiting fellows or referral partners.

But if you carve out a niche like trauma care for factory workers or mobile follow-up for joint replacements, then you can stand out and grow fast.

Pros:

• Strong salary around $557k with affordable living costs
• Huge demand in shortage zones means instant patient volume
• Low startup costs for office space, equipment, and staffing
• Community outreach builds your name and trust quickly

Cons:

• Some patients may have limited ability to afford high-end care
• New implant/device trials often reach Detroit after coastal hubs
• Harsh winters can be a downside for new hires or patient travel
• Economic shifts may affect local insurance coverage

7). Roanoke, VA

Want a calmer pace, good pay, and space to grow? Roanoke checks those boxes.

The average orthopedic salary here is about $513,000, and living costs run roughly 9% below the national average. That means your money stretches farther—for housing, schools, even clinic rent. For orthopedic surgeons who want balance, this smaller city might feel just right.

And there’s real demand.

Carilion Clinic keeps expanding, including a major new hospital tower coming in 2025. More space means more OR access and more referrals. Fewer local surgeons means less competition, too. In a metro area with around 315,000 people, word-of-mouth travels fast. Offer joint replacements or sports care, and you could become the go-to ortho within a year.

Still, Roanoke has limits.

The population is smaller, so you won’t see as many complex or high-end cases. Device trials usually hit bigger cities first. And some patients or payers might have tight budgets. But if you’re building from the ground up, with a focus on community and lifestyle, Roanoke gives you the freedom to grow without the pressure of a crowded market.

Pros:

• Average salary around $513k with below-average cost of living
• Carilion’s growth brings more referrals and OR time
• Low competition helps you build a fast reputation
• Startup costs stay low for rent, staff, and equipment

Cons:

• Smaller population means fewer advanced cases
• Big device trials may reach here later
• Budget limitations can affect payer mix
• Growth may plateau once the local market is captured

8). Sacramento–Roseville–Arden-Arcade, CA

Sacramento feels like the middle lane on California’s freeway. You’re still in the Golden State, but your paycheck stretches a lot further.

The average orthopedic salary here is around $527,000. Meanwhile, cost of living is about 33% lower than San Francisco. That’s a huge gap—especially when it comes to rent, groceries, or starting a clinic. For surgeons who want California perks without the superstar price tag, this area hits a sweet spot.

The patient base is growing too. The metro population passed 2.26 million in 2025 and it keeps inching upward. UC Davis Health just broke ground on a new 14-story hospital tower, and Sutter is building a downtown sports-medicine complex. More beds, more clinics, and more referrals is a great news if you do joint replacements, spine care, or fracture work.

And unlike coastal cities, office rent and staff wages stay manageable. That makes it easier to open your own practice without draining your savings.

Still, growth attracts competition.

Big hospital groups and outpatient surgery centers are already busy claiming turf. To stand out, you’ll need a clear angle, umm, maybe same-day knees, biologic repairs, or ergonomic care for California’s state workers. If you can find your lane, Sacramento gives you room to grow without the burnout.

Pros:

• Strong average pay near $527k with lower costs than SF or LA
• Population is rising, driving steady demand
• Big investments from UC Davis and Sutter mean more OR access
• Lower startup costs for office space and staffing

Cons:

• Growing competition from hospitals and ASCs
• Need to carve out a niche to stay booked
• Fewer early research trials compared to the big-name academic centers

9). Dallas-Fort Worth-Arlington, TX

You want plenty of cases, solid pay, and bills you can actually manage. Dallas-Fort Worth makes a strong case.

The average orthopedic salary here is about $550,000, and living costs are just slightly above the national average. That means your paycheck stretches a lot more than it would on the coasts.

The metro population now tops 6.7 million—and it’s still growing. About 1% every year. That’s a huge base of knees, hips, and sports injuries waiting for help.

Jobs? You’ve got options.

Big health systems like Baylor Scott & White and Texas Health Resources are expanding fast. Baylor’s new medical center on PGA Parkway opens this summer. Texas Health’s Justin Tower adds tons of ortho-ready ORs. That means more operating room time, research partners, and steady referrals for new orthopedics.

If you’re thinking about opening your own place, Dallas is friendly to startups. Office space and staffing costs are much lower than California, so buying into an ASC or launching a clinic won’t leave you buried in debt. Plus, the population stays active—think joint replacements, spine care, and sports medicine for kids and teens.

But it’s not all easy.

Competition is real. New ASCs are popping up all the time, and other surgeons are chasing the same total-joint cases. To stay ahead, you’ll need a niche or standout patient care. And the heat? Summers here are long and hot, which can be a dealbreaker for some staff and patients.

Pros:

• Average salary around $550k with manageable living costs
• Large, growing metro with strong case demand
• Big hospital expansions offer OR time and referrals
• Lower startup costs compared to coastal cities

Cons:

• Competition from fast-growing ASC and ortho groups
• Hot summers may impact recruitment and patient volume
• You’ll need strong branding or a subspecialty to stand out

10). Charlotte-Concord-Gastonia, NC

Charlotte hits a sweet spot if you want big-city medicine without big-city prices.

The average orthopedic salary here is around $538,000, and living costs are just slightly below the national average. That combo means your paycheck actually goes somewhere—unlike in San Francisco or New York.

Job options? Plenty.

Atrium Health is building a new care tower and adding more surgical suites. Novant and OrthoCarolina are hiring too. Whether you want hospital work, an outpatient clinic, or an ASC, you can get started quickly.

Thinking about opening your own place? Charlotte’s population is growing fast—about 117 new residents move in every day. That means more knees, hips, and sports injuries to treat. Office rent and staff wages stay lower than in coastal cities, so starting a private clinic feels doable. Families here care about staying active, so if you offer sports medicine, pediatric ortho, or fast-track joint recovery, you’ll stand out.

There’s just one thing: others are catching on.

More surgeons and ASCs are moving in, which makes referrals harder to secure. You’ll need a clear niche or strong service style to stay top-of-mind. But get it right—and Charlotte becomes one of the best places to grow your ortho career and still have time for life outside the clinic.

Pros:

• Solid average pay around $538k with affordable living costs
• Atrium Health expansion means more OR space and referrals
• Fast-growing population feeds consistent patient demand
• Lower rent and wages make private practice more realistic

Cons:

• Rising number of surgeons and ASCs increases competition
• Fewer high-level research opportunities than big academic centers
• You’ll need strong branding or a subspecialty to stay ahead

Key Factors to Consider When Choosing a Location

Thinking about where to live and work as an orthopedic surgeon in the U.S.?

The city you choose can shape your professional growth, lifestyle, and long-term financial health.

So before packing your bags, you must know the essential factors that should be on your radar:

• Average Salary

When evaluating cities, look at the average salary for orthopedic surgeons. Higher wages often reflect a stronger demand for orthopedic care and a healthier reimbursement environment.

But don’t stop there—dig deeper. Ask yourself:

Is the higher salary tied to longer work hours?

Does it come with better resources or more administrative headaches?

For example, orthopedic surgeons in cities like San Francisco or New York might earn top dollar, but higher living costs and more rigid licensing rules can offset that income.

• Population Growth

A growing city often means an ever-increasing patient base: more families, aging populations, and sports-related injuries—all great news for orthopedic practices.

For example, Charlotte, NC, attracts young professionals and retirees who could benefit from orthopedic care. Think of population growth as planting your practice in fertile soil—the more the community grows, the more your patient list can flourish.

• Healthcare Infrastructure

Being near hospitals, surgery centers, and physical therapy clinics can significantly boost your practice’s accessibility and referral network.

It’s also more convenient for your patients, which increases retention.

A physician moved his orthopedic clinic to Manistee, MI because it placed him beside the hospital.

That proximity improved patient access and made scheduling surgeries more efficient.

• Competition 

You’ll want to evaluate how many orthopedic surgeons are already practicing there.

A saturated market can make it harder to establish yourself—especially if you’re starting a solo practice.

On the flip side, underserved areas might offer golden opportunities, mainly if you specialize in sports medicine, joint replacement, or spine surgery.

Research the local demand and consider what makes your approach unique—then find a city where that niche is in need.

• Cost of Living 

A high salary sounds great—until you realize your rent, taxes, and staff wages are equally high. That’s why the cost of living matters.

Cities with a lower cost of living can significantly boost your take-home income and reduce the pressure on your practice’s bottom line.

For example, setting up shop in Tulsa, OK, could mean lower rent, more affordable housing, and a higher quality of life without sacrificing earning potential.

Top 10 U.S. Cities for Orthopedic Surgeons: Quick Comparison Guide

Looking for the right place to grow your orthopedic career or launch a new practice? Here’s a quick-glance summary of the best cities across the U.S.

If you plan to treat Medicare or Medicaid patients, you must clear every CMS credentialing requirement first. Skip a step and you risk landing on the dreaded “red list,” which means zero reimbursement. Relax, though: credentialing is not rocket science. Think of it as brewing your morning coffee—simple, but you still need the right steps.

In this guide, you will learn about:

• Provider enrollment basics (PECOS, CMS-855I, CMS-855B)
• Medicare and Medicaid credentialing checklists
• Telemedicine credentialing rules for virtual visits
• Delegated credentialing and how large groups speed things up

As a medical billing specialist, I have helped thousands of clinics move from pending to paid status without a single denial. You can do the same. Follow along and see how to:

• Build a spotless CAQH profile
• Avoid common credentialing denials
• Keep your NPI linked to the correct taxonomy code
• Meet every re-credentialing deadline

Have questions like “How do I join Medicare as a new provider?” or “What is the fastest way to update PECOS?” They are answered here. By the end, you will know exactly what CMS expects, which forms to file, and how to stay on the green list so your healthcare claims get paid in full and on time.

CMS Credentialing Requirements for Healthcare Providers in the USA

CMS (Centers for Medicare & Medicaid Services) credentialing requirements refer to the processes and standards that healthcare providers must meet in order to be approved for participation in Medicare and Medicaid programs. 

Some of the basic requirements are:

1). Obtain Your National Provider Identifier (NPI)

The initial step in the CMS credentialing process is obtaining your NPI number. It is a 10-digit identifier utilized for all healthcare billing, including payment for Medicare and Medicaid. You will not be able to send in or get reimbursed for any claims if you do not have it.

Application for your NPI is possible through the National Plan and Provider Enumeration System (NPPES). The application involves basic information such as your name, practice address, tax ID, contact information, license, and credentials.

The majority of healthcare professionals register for the NPI first, since they will also require it during later PECOS registration and CMS enrollment.

Having an NPI is among the most usual prerequisites for any medical billing operation. It ensures that CMS and payers are able to track who is offering the services, particularly for specialties such as family medicine, behavioral health, or physical therapy.

2). Ensure Your License is Current and Validated

You will need a current and unrestricted license to practice in the state in which you will be treating patients. CMS will not accept an expired or restricted license, and they will check for this information when you are enrolling.

Depending on your provider type, you may also be asked to furnish proof of board certification or further training. For instance, some positions, such as cardiologists or nurse anesthetists, will require additional credentials.

The CMS also cross-checks the Office of Inspector General (OIG) List of Exclusions. In case you have participated in healthcare fraud, abuse, or other disqualifying conduct, you will be excluded from participation in Medicare. This is done to make sure that nothing but eligible health care providers are permitted to charge Medicare and Medicaid.

3). Fill out the CMS Enrollment Forms or Use PECOS

Once your licensure and NPI are verified, the following step is to formally enroll in Medicare. You may do this by filing the respective CMS-855 form or by enrolling online through PECOS, or Provider Enrollment, Chain, and Ownership System.

Every form has a particular function:

• Individual healthcare providers, such as physicians, therapists, and nurses, use CMS-855I.
• The CMS-855B is utilized for group practices and clinics.
• CMS-855A is for institutional providers, including hospitals and nursing facilities.
• CMS-855R is for reassigning Medicare benefits to an entity, such as a group or an organization.

PECOS is the most popular choice among providers as it enables quicker submission and immediate tracking of application status. Filing the incorrect form or omission of documentation will hold up your credentialing process by a great deal, hence you need to do this step with care.

4). Credentialing by a Medicare Administrative Contractor (MAC)

During CMS enrollment, every provider passes through a Medicare Administrative Contractor for review. A MAC is a private firm that manages Medicare enrollment, handles claims processing, and verifies provider credentials within its region.

A MAC checks your forms, confirms your license, and makes sure every supporting document is in place. If something is missing, you receive a request for more information instead of a flat denial. Processing times vary by region, so keep local timelines in mind.

When the MAC approves your file, CMS issues a Provider Transaction Access Number (PTAN). You will need this PTAN whenever you submit Medicare claims or update your record in PECOS.

Smooth MAC credentialing sets the stage for trouble-free billing with Medicare beneficiaries.

5). Medicare Participation Agreement

After credentialing, CMS asks you to sign a Medicare Participation Agreement. This short contract spells out what you agree to when you treat Medicare patients.

• You follow all CMS regulations, including coding rules, reimbursement limits, and fraud-prevention policies.
• You accept the Medicare fee schedule as full payment, except for allowed coinsurance or deductibles.
• You send clean claims on time and bill only for medically necessary services.
• You maintain quality-of-care standards, which CMS may audit through its quality reporting programs.

Once the agreement is on file, you can begin seeing Medicare patients and submitting electronic claims without delay.

6). Ongoing Compliance with Federal and State Rules

CMS approval is not the finish line. Providers must stay current with both federal regulations and state requirements to keep billing privileges active.

➜ Federal rules

• Medicare Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)
• HIPAA privacy and security safeguards
• Policies in the Affordable Care Act that affect provider enrollment
• Current CMS billing and coding guidelines

These standards apply to physicians, therapists, hospitals, home health agencies, and every other Medicare-enrolled entity.

➜ State rules

• Professional licensure laws require an active, unrestricted license in each state where you practice.
• Scope-of-practice statutes limit which services your license allows you to perform.
• Each state Medicaid program has its own enrollment steps that build on federal guidance.
• Managed Care Organizations (MCOs) may add extra credentialing checks before they will contract with you.
• State privacy laws, such as California’s CCPA, can be stricter than HIPAA.
• If you deliver telehealth, you must follow every state’s telemedicine and cross-state licensure rules.

Meeting these federal and state obligations helps you avoid claim denials, overpayment recoupments, and potential exclusion from government programs.

7). Clear Background Check

CMS only accepts providers whose records are clean. During both initial credentialing and the three-year recredentialing cycle, CMS runs a background check that looks at professional qualifications, criminal history, and any past Medicare fraud or abuse. Failing this review can delay or deny enrollment, revoke billing privileges, and trigger legal or financial penalties.

What CMS reviews:

• Criminal convictions at the federal or state level
• Medicare and Medicaid exclusion lists
• License status plus any disciplinary actions
• Malpractice claims and settlements
• Education, training, and residency verification

8). Malpractice Insurance Requirements

Every provider must carry active malpractice (professional liability) insurance to protect patients and themselves against errors or negligence claims. CMS checks coverage at enrollment, at recredentialing, and during random audits.

• Most plans require at least one million dollars per claim and three million dollars aggregate each year, although limits can vary by state or specialty
• A current Certificate of Insurance (COI) must list the insured name, policy number, coverage dates, limits, and carrier
• Providers changing jobs or retiring may need tail coverage to insure prior acts

Without proof of adequate coverage, CMS can deny enrollment or terminate participation.

9). Meeting CMS Quality Standards

CMS expects all enrolled professionals and facilities to deliver safe, effective, and high-quality care. Compliance is also tied to value-based payment models.

Key quality checkpoints:

• Adhering to Medicare Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)
• Reporting through MIPS if eligible
• Tracking and submitting Clinical Quality Measures (CQMs)
• Failure to meet these benchmarks can reduce reimbursement or trigger corrective action plans.

10). Provider-Specific Rules

CMS tailors requirements to the provider’s role.

• Pharmacists, physician assistants, and other non-physician practitioners may need proof of specialty certification or documented supervision
• Telemedicine professionals must hold a valid license in each state where patients are located and meet state-specific virtual-care rules

11). Additional Certifications CMS May Require

Depending on services offered, you might need extra credentials alongside standard Medicare enrollment.

12). Site Visits and Operational Standards

CMS may conduct on-site inspections during initial enrollment, revalidation, or whenever red flags arise. Inspectors confirm that:

• The office address on your application physically exists and matches signage
• Posted hours are accurate and staff are present
• Patient-care areas, record storage, and equipment meet health and safety rules
• Policies align with HIPAA, infection control standards, and local building codes

Passing the site visit proves that your practice is real, operational, and ready to serve Medicare and Medicaid beneficiaries.

CMS Telemedicine Credentialing Requirements

Telemedicine follows the same core CMS enrollment rules as in-person care, yet it adds a few extra layers that reflect the unique, screen-to-screen setting. Providers who plan to deliver virtual visits to Medicare or Medicaid patients must meet each standard below to secure reimbursement and avoid claim denials.

Here are the key CMS telemedicine credentialing requirements:

Provider Enrollment

• Complete the correct CMS-855 application and choose the telemedicine service type when prompted.
• Submit your National Provider Identifier (NPI), proof of active license, malpractice coverage, and any state-specific forms.
• Keep your information current in PECOS so payers can verify your status before processing remote-care claims.

Licensure Across State Lines

• Hold an active license in the state where the patient sits during the visit, even if you live elsewhere.
• Many providers rely on the Interstate Medical Licensure Compact or similar nursing and psychology compacts to speed up multi-state approval.
• Track renewal dates carefully; an expired out-of-state license can halt payment for every virtual visit.

HIPAA-Compliant Technology

• Use a HIPAA-compliant telemedicine platform for video, chat, and file sharing.
• Encrypt data in transit and at rest, maintain audit logs, and restrict user access to the minimum necessary.
• Provide patients with the standard Notice of Privacy Practices that explains how their data is stored and shared.

State and Federal Telemedicine Rules

• Follow your state’s practice standards, prescribing limits, and modality restrictions for virtual care.
• Some states enforce payment parity laws that require commercial plans to cover telehealth at the same rate as face-to-face visits; CMS often mirrors these rules for Medicaid.
• Document each visit just as thoroughly as an in-office encounter, including location of patient and provider.

Patient Consent

• Obtain informed telehealth consent before the first virtual session of the patient.
• Explain how the service works, any technology risks, and steps taken to secure data.
• Keep a signed or electronically acknowledged consent form on file, as CMS may request it during audits.

Supervision and Delegation

• If nurse practitioners, physician assistants, or other clinicians deliver remote care, meet CMS and state supervision or collaboration requirements.
• Clearly outline who can provide which services, how oversight is documented, and how escalation to a supervising physician occurs.

CMS Delegated Credentialing Requirements

Sometimes a health plan or large provider group lets a separate entity handle day-to-day credentialing. This is known as delegated credentialing and it comes with its own set of CMS rules. Even when the work is handed off, the original organization is still responsible for meeting every CMS standard.

Here are the key CMS delegated credentialing requirements:

Formal Delegation Agreement

A clear, written agreement must be in place before any work starts. The document should

• list every task the delegate will complete, such as primary-source verification or final credentialing decisions
• spell out performance targets and how results will be reported
• describe how the delegating organization will monitor, audit, and if needed, cancel the arrangement
• require the delegate to follow NCQA or an equivalent set of credentialing standards when the health plan is NCQA-accredited

Oversight and Accountability

The health plan—or other delegating group—keeps full responsibility for compliance. To show CMS that proper oversight exists, the plan must

• review and approve the delegate’s policies and procedures before work begins
• audit the delegate, usually once a year, to confirm rules are being followed
• maintain written records of every review, audit, and corrective action
• step in quickly if audits reveal non-compliance

Credentialing Standards to Maintain

The delegate has to apply all routine credentialing checks, including primary-source verification of

• active state license and any required specialty license
• DEA certificate if the provider prescribes controlled substances
• board certification when the specialty calls for it
• education, training, and recent work history
• current malpractice insurance with adequate limits
• sanctions, disciplinary actions, and the OIG exclusion list

These safeguards ensure every provider in the network is licensed, competent, and in good standing.

Revoking or Correcting Delegation

If audits show that credentialing standards are not met, the health plan must

• issue a corrective action plan with clear deadlines
• revoke the delegation if problems persist
• resume direct credentialing in-house or choose a new, compliant delegate

By keeping a close eye on every delegated activity, the health plan protects patients and stays aligned with all CMS credentialing regulations.

FAQs

What is CMS credentialing and why does it matter?

CMS credentialing is the process that confirms a provider’s identity, professional qualifications, and compliance record before allowing Medicare or Medicaid billing. Without it, claims will be rejected and you cannot treat covered patients.

Which core documents do I need to start a CMS application?

You will need an active state license, National Provider Identifier (NPI), malpractice insurance certificate, work history, education and training records, and a completed CMS-855 application (or the PECOS online equivalent).

How long does initial credentialing for CMS usually take?

Most clean applications pass through a Medicare Administrative Contractor in thirty to ninety days. Missing paperwork, pending license renewals, or background issues can extend the timeline.

How often must I complete CMS recredentialing or revalidation?

CMS requires recredentialing every three years for all enrolled providers. A separate revalidation notice can arrive sooner if you move, change ownership, or trigger other risk factors.

What is the difference between a CMS-855 paper form and PECOS?

CMS-855 is the paper enrollment packet. PECOS is the secure online portal that lets you fill out the same information electronically, upload documents, and track your application status. Use one method per enrollment cycle.

Can my practice delegate CMS credentialing to a Credentialing Verification Organization (CVO)?

Yes. A formal delegation agreement must spell out the CVO’s duties, performance standards, audit schedule, and termination clauses. Even with delegation, your organization remains accountable for meeting every CMS rule.

Does CMS perform site visits and why?

Yes. CMS or its contractor can conduct a site visit during initial enrollment, revalidation, or when they detect billing anomalies. Inspectors verify that the listed address exists, hours are posted, staff are present, and records are secure.

Do I need a separate state license for each location where patients are treated, including telehealth?

Yes. You must hold an active license in every state where the patient is located at the time of service. This applies to both in-person care and telemedicine appointments.

Moving on, getting cardiography coding right is essential because it affects everything. Be it patient bills, insurance coverage or the overall quality of healthcare revenue cycle management.

What exactly is non-surgical cardiography?

It refers to heart-imaging or heart-monitoring tests done without an incision. These tests help doctors see how the heart is working without a surgical procedure. Furthermore, they lay a foundation in diagnosing or managing several heart conditions.

In this blog, we’ll go over some common non-surgical cardiography procedures you might see in cardiology system coding. Also, learning about these tests in advance makes coding easier and more accurate.

Before we dive into the non-invasive cardiology procedures, let’s have a quick look at the working of cardiology coding.

How Cardiology Coding Works?

Cardiology procedures are primarily coded using Current Procedural Terminology (CPT) codes in the U.S. Basically, these codes describe medical, surgical, and diagnostic services. And for international or inpatient coders, the ICD-10-PCS system may be used. But for most outpatient non-surgical cardiography, CPT is your go-to.

Non-Surgical Cardiography Procedures found in the Cardiovascular System Coding

Top Non-Surgical Cardiography Procedures & Common CPT Codes

Non-surgical cardiography procedures play a vital role in diagnosing and monitoring heart conditions. These tests are commonly used in cardiology practices, urgent care settings, and hospitals. 

Furthermore, it’s important to know how to choose the correct CPT and ICD-10-PCS codes for these tests. Because using the right codes helps make sure that billing is accurate and insurance payments aren’t delayed. 

Here is a list of the most common non-invasive heart tests, along with the codes used for outpatient (CPT) and inpatient (ICD-10-PCS) billing.

1). Electrocardiogram (ECG / EKG)

What it is: A quick, painless test that records the heart’s electrical activity using electrodes placed on the skin.

Why doctors order it: To detect arrhythmias, ischemia, and signs of a recent or ongoing heart attack.

CPT Codes:

• 93000 – Complete (includes both tracing and interpretation)
• 93005 – Tracing only
• 93010 – Interpretation only

ICD-10-PCS: 

• 4A02X4Z – Monitoring of cardiac rhythm, external

2). Holter Monitor (24 to 48-Hour ECG)

What it is: A portable device that continuously records heart rhythms for 24–48 hours.

Why doctors order it: To identify irregular heartbeats that may not appear during a standard ECG.

CPT Codes:

• 93224 – Full service (global)
• 93225 – Device hookup and patient instructions
• 93226 – Technical recording and monitoring
• 93227 – Final interpretation and report

ICD-10-PCS: 

• 4A02X4Z – Monitoring of cardiac rhythm, external

3). Event Monitor (Loop Recorder)

What it is: A wearable or implantable device that captures abnormal heart rhythms when activated by symptoms or automatically.

Why doctors order it: Used for long-term heart rhythm monitoring, especially in patients with fainting spells or dizziness.

CPT Codes:

• 93268 – External loop recorder (global)
• 93270 – Setup and education
• 93271 – Data recording and transmission

ICD-10-PCS: 

• 4A02X4Z – Monitoring of cardiac rhythm, external

4). Transthoracic Echocardiogram (TTE)

What it is: A heart ultrasound using a probe on the chest wall.

Why doctors order it: To evaluate heart valves, muscle function, chamber size, and ejection fraction.

CPT Codes:

• 93306 – Complete echocardiogram with Doppler and color flow
• 93307 – Complete echocardiogram without Doppler
• 93308 – Limited or follow-up study

ICD-10-PCS: 

• B245ZZ3 – Ultrasonography of heart, transthoracic, real-time

5). Stress Tests (Exercise or Pharmacologic)

What it is: Measures heart response to stress from exercise or medication.

Why doctors order it: To detect ischemia or reduced blood flow in patients with symptoms like chest pain or shortness of breath.

CPT Codes:

• 93015 – Complete stress test with supervision, interpretation, and report
• 93016 – Supervision only
• 93017 – Tracing only
• 93018 – Interpretation and report only

6). Stress Echocardiography

What it is: Combines exercise (treadmill or bicycle) with echocardiography imaging.

Why doctors order it: To evaluate blood flow and heart wall movement under stress conditions.

CPT Codes:

• 93350 – Echocardiographic imaging during stress
• 93351 – Full package: stress echo with supervision, interpretation, and report

ICD-10-PCS: 

• B245ZZ3 – Transthoracic ultrasonography with stress (exercise or pharmacologic)

7). Dobutamine Stress Echocardiography

What it is: Uses the drug dobutamine to simulate exercise in patients who cannot physically exert themselves.

Why doctors order it: To assess cardiac function when exercise stress testing isn’t possible.

CPT Codes:

• 93350 – Stress echo imaging only
• 93351 – Stress echo with supervision and interpretation

ICD-10-PCS: 

• B245ZZ3 – Real-time ultrasound of heart under pharmacologic stress

8). Cardiac CT for Calcium Scoring

What it is: A non-contrast CT scan that measures calcium buildup in coronary arteries.

Why doctors order it: Risk assessment for coronary artery disease in patients with no symptoms.

CPT Code:

• 75571 – CT scan of heart without contrast (calcium scoring)

ICD-10-PCS: 

• B210YZZ – CT scan of heart without contrast

9). Cardiac CT Angiography (CCTA)

What it is: A CT scan with contrast that produces 3D images of coronary arteries.

Why doctors order it: Helps detect blockages, plaque buildup, or congenital heart defects.

CPT Codes:

• 75572 – CT with contrast for heart structure and function
• 75573 – CT with contrast for congenital heart disease
• 75574 – CT with contrast and 3D post-processing

ICD-10-PCS: 

• B2101ZZ – CT scan of heart with contrast

10). Cardiac MRI

What it is: A magnetic resonance scan providing highly detailed imaging of the heart.

Why doctors order it: Detects scarring, structural abnormalities, cardiomyopathies, and congenital heart defects.

CPT Codes: 

• 75557 – MRI of heart without contrast
• 75559 – MRI of heart with contrast
• 75561 – MRI of heart with and without contrast
• 75563 – MRI of heart with stress imaging
• 75565 – Cardiac MRI with flow mapping

ICD-10-PCS:

• B030ZZZ – MRI of heart

11). Myocardial Perfusion Imaging (Nuclear Stress Test)

What it is: A nuclear medicine scan that shows how well blood flows to the heart muscle during rest and stress.

Why doctors order it: To diagnose coronary artery disease, especially in patients with chest pain or reduced exercise tolerance.

CPT Codes: 

• 78451 – Single study at rest or stress
• 78452 – Multiple studies (rest and stress)
• 78453 – Planar imaging, single study
• 78454 – Planar imaging, multiple studies

ICD-10-PCS: 

• C220ZZZ – Planar nuclear medicine imaging of heart

Common Mistakes in Cardiography Coding and How to Avoid Them

Let’s have a look at the top mistakes made when coding non-invasive cardiology procedures, along with the tips to avoid them:

Using the Wrong or Old CPT Codes

Many coders accidentally use CPT codes that are out of date or don’t match the actual service performed. For example, using a full-service (global) code when only the interpretation was done.

How to avoid?

First, always check that you’re using the latest CPT codes. Secondly, be clear on what part of the service was provided either just the test or just the reading, maybe even both. Also, use modifiers like -26 for the doctor’s interpretation or -TC for the testing part only.

Example: Use 93000 if the ECG test and interpretation are both done. Use 93010 with modifier -26 if only the doctor’s reading is billed.

Not Matching the Right ICD-10 Diagnosis Code

Sometimes, the test is billed correctly, but it gets denied because the diagnosis code doesn’t explain why the test was needed. This often happens when coders use unclear or general diagnosis codes.

How to avoid?

Use specific ICD-10 codes that clearly show the test was medically necessary. Don’t just use general codes, check payer rules or tools like Medicare’s LCD/NCD lists to see which diagnoses are allowed for each test.

Tip: Create a quick-reference list of the most common ICD-10 codes used with each cardiology test.

Billing for Procedures That Are Already Bundled

Some non-invasive tests are bundled together by insurance, meaning they are paid as one service. But, coders may bill them separately by mistake, which can lead to denials or audits.

How to avoid?

First of all, check the NCCI edits to see if two procedures are bundled. If they’re normally billed together, but in your case they were truly separate, you may need to use a modifier like -59. Also, make sure your documentation clearly supports this.

Example: If you bill an Echocardiogram and a Doppler together, you must show they were both needed and done for different reasons, not just part of a routine test.

Misusing or Forgetting Modifiers

Modifiers help tell the full story of a service. For example, they explain whether only a part of it was done, or if it was separate from another procedure. Usually, many coders either forget to add the necessary modifiers or use the wrong ones. This can lead to underpayment, denials, or incorrect claims.

How to avoid?

Understand when and how to use common cardiology modifiers like:

Always make sure the documentation supports the modifier. Don’t just use them just to bypass edits, use them only when truly needed.

Example: If a Holter monitor is provided by an outside facility but interpreted in your office, use modifier -26 with the CPT code to bill only for the interpretation.

Quick Checklist for Easy and Accurate Cardiography Coding

Here is a quick checklist for you to follow. You’ll reduce billing mistakes, get paid faster, and make life easier for everyone in your cardiology practice.

Know What Test Was Done

First, understand if it’s a diagnostic, monitoring, or imaging test. Each one comes with different CPT/ICD codes.

Use the Right CPT Code

Double-check that you’re not using outdated codes. Refer to the AMA or coding software for updates.

Always Match CPT with the Right Diagnosis (ICD-10)

Avoid non-specific diagnosis codes. Use a diagnosis code (ICD-10) that clearly shows why the test was needed.

Don’t Forget Modifiers

Use modifiers like -26 (doctor’s part), -TC (test only), or -59 (separate service) when needed.

Watch for Bundled Services

Some tests are combined into one code. Use NCCI edits to prevent unintentional unbundling. Use modifier -59 only when services are truly distinct.

Check Insurance Rules

Every insurance plan is different, look up coverage rules before billing.

Document Everything Clearly

Ensure provider notes clearly explain what was done, why it was necessary, and who performed which part of the test.

Conclusion

Non-surgical heart tests may be simpler than surgical cardiography procedures, but coding them correctly requires the same focus. Also, knowing which non-surgical cardiography procedures are included in cardiology system coding is super important. Furthermore, these tests like ECGs, Echocardiograms, Stress tests, and Heart scans help doctors check heart health without any surgery.

Moreover, using the right CPT and ICD-10-PCS codes, checking the diagnosis, and adding the right modifiers can make a big difference in getting paid on time and avoiding rejections. Good coding helps patients, doctors, and cardiology billing teams all stay on track.

To sum up, when you know the right non-surgical heart tests and how to code them properly, you’ll avoid billing errors, reduce claim rejections, and make the whole process smoother for everyone.

If you have ever wondered “in what format are healthcare claims sent?” this guide answers that question and shows how the right claim submission format keeps healthcare reimbursements moving.

A clean claim starts the payment clock. Use the wrong healthcare claims format or leave out key data, and the clock stops. Insurers then delay, reduce, or even refuse payment. Knowing what format healthcare claims are submitted in—and using it every time—guards your cash flow.

You will hear two close‑sounding terms: ‘form’ and ‘format’. They sound alike, but here’s an easy way to keep them straight:

• Form = paper. Think CMS‑1500 or UB‑04.
• Format = electronic. Think files that zip through secure networks.

That shift from form to format changes the game. Paper forms still work for a few small offices, yet they move at postal speed and add data‑entry risk. In contrast, an electronic medical claim form format reaches the payer in minutes and meets every HIPAA‑compliant medical claim format rule.

Most healthcare providers now rely on the HIPAA‑compliant 837 electronic insurance claim format because it moves fast and cuts errors. The 837 family has three files:

• 837P (Professional): office visits, lab work, therapy, and other outpatient care
• 837I (Institutional): hospital stays, skilled‑nursing days, and other facility fees
• 837D (Dental): cleanings, fillings, crowns, and all oral services

Additionally, pharmacies follow a different (but equally strict) insurance claim format called NCPDP for every prescription they fill.

⫘⫘⫘⫘⫘⫘

In the United States, healthcare claims move in matched pairs of paper and electronic files. When paper is still required, providers mail the CMS-1500 for office services, the UB-04 (CMS-1450) for hospital or facility charges, and the ADA Dental Claim for tooth work.

Day-to-day, those same claims travel faster as their electronic twins—the CMS-1500 turns into the 837P, the UB-04 turns into the 837I, the ADA form turns into the 837D, and every paper pharmacy slip converts to the NCPDP telecom file. All four digital files ride on secure EDI, making them the standard format for submitting medical claims today.

⫘⫘⫘⫘⫘⫘

What is meant by the ‘format’ of a Healthcare Claim?

When people ask “in what format are healthcare claims sent?” they are talking about the exact layout—paper or electronic—that tells an insurer who was treated, what was done, when it happened, and how much it cost. In the United States, providers must send this information in a HIPAA‑compliant medical claim format so the payer can read it, check it, and pay it without delay.

Every claim line follows a standard format for submitting medical claims and carries well‑known code sets:

• ICD‑10‑CM — pinpoints the diagnosis
• CPT® or HCPCS — shows the procedure or service
• NDC, HCPCS Level II, or revenue codes — identify supplies, drugs, devices, or medical transport

Using the right healthcare claims format reduces back‑and‑forth, slashes errors, and speeds up cash flow. Put simply, the format is the blueprint that turns clinical work into dollars received.

Who decides the healthcare claim submission format?

Before you hit “send,” you need to know who writes the rules. In U.S. healthcare, four main bodies define what format healthcare claims are sent in and how those files must look. Master their playbook, embed them in your practice management software, and your claims move from “pending” to “paid” much faster.

1). Centers for Medicare & Medicaid Services (CMS)

CMS issues the familiar paper layouts, called the CMS‑1500 for professional services and the UB‑04 for hospital billing and facilities. Even in an e‑first world, many healthcare payers still scan these forms, so clean, crisp fields matter. As a healthcare provider, you need to follow every box, line, and font cue so that your paper claim sails through optical‑character recognition with fewer manual touch‑ups.

2). Accredited Standards Committee X12 (often called ANSI X12)

When you switch to electronic, X12 owns the road. Its 837P, 837I, and 837D EDI loops translate your service lines into machine‑readable data. The latest release—HIPAA version 5010—locks down field length, segment order, and code sets. Submit an 837 file that matches X12 specs and most clearinghouses will approve it in minutes.

3). National Council for Prescription Drug Programs (NCPDP)

Need to bill a pharmacy claim? NCPDP frames the real‑time electronic medical claim format for retail, mail‑order, and specialty drugs. It syncs each NDC code, quantity, and day‑supply field so the payer’s drug‑utilization engine can check safety and price in a single ping.

4). Health Insurance Portability and Accountability Act (HIPAA)

HIPAA is the federal backbone. It mandates that every covered entity—clinic, dentist, hospital, or health plan—uses a HIPAA‑compliant medical claim format and safeguards patient data at rest and in flight. Fail to follow these guardrails and you risk fines, data breaches, and slow payment.

Types of Healthcare Claim Form formats

1). the CMS‑1500 Paper Claim Format

Even in the EDI era, some payers still need a paper file. That file is the CMS‑1500 form. It is the standard insurance claim format for solo doctors, therapists, labs, and other non‑facility providers. Think of it as the paper twin of an 837P file. If you mail or fax a claim, this is the one that lands on the payer’s scanner.

Why CMS‑1500 is a standard claim format?

The CMS‑1500 is more than a sheet of paper. It follows firm layout rules that turn your data into a machine‑ready healthcare claims format:

• Fixed field map. Each red box lines up with a matching data field in HIPAA’s 837P file. That one‑to‑one link keeps your claim submission format in sync whether you print or send EDI.
• Code sets locked in. The form forces you to use ICD‑10‑CM for diagnoses, CPT®/HCPCS for services, and your ten‑digit NPI for provider ID. Those sets make the file a HIPAA‑compliant medical claim format by design.
• Scanner‑friendly ink. The “drop‑out” red ink lets optical readers lift each character cleanly. A clear scan speeds the payer’s first‑pass edit and cuts denials.

Because its layout never changes, the CMS‑1500 acts as a standard format for submitting medical claims (even when you submit on paper).

Why polish your CMS‑1500 workflow?

• Fewer re‑works. A tight, HIPAA‑compliant medical claim format gets past OCR edits on the first scan.
• Quicker cash flow. Clean paper claims can still clear in ten business days. This is vital when clearinghouses are down.
• Easy pivot to EDI. Every well‑filled CMS‑1500 mirrors the field order of an 837P. When you upgrade, the map is ready.

2). the UB‑04 (CMS‑1450) Facility Claim Format

Hospitals, rehab centers, and skilled-nursing homes do not bill on the CMS‑1500 claim format. Instead, they use the UB‑04 form, also called CMS‑1450. This single page carries every charge for a full stay—room, board, drugs, supplies, lab work, even the swing‑bed fee. So if you ask in what format are healthcare claims sent for facilities?, the answer is almost always UB‑04 in paper or 837I in EDI.

What makes the UB‑04 a standard format?

• Fixed line map. Every line has a locator number (FL 01–81). That grid links one‑for‑one with the 837I segments in a HIPAA 5010 file, keeping your healthcare claims format consistent across paper and electronic routes.
• Revenue codes first. Each charge line starts with a three‑digit revenue code, then the CPT®/HCPCS code when needed. This layout meets the healthcare claim submission format requirements that drive auto‑adjudication.
• Header holds payer data. The top blocks lock in Medicare, Medicaid, or private plan IDs. Drop the wrong payer code and the claim bounces before anyone checks medical need.

Sections you must get right:

• Patient and subscriber data (FL 12–17). Copy the name, date of birth, and member ID exactly from the card.
• Occurrence and value codes (FL 31–41). These tiny two‑digit flags mark why the stay started, when benefits kicked in, and how much the patient paid.
• Service lines (FL 42–47). List each daily room rate, therapy charge, or drug cost on its own line so the payer’s system can total them.

3). the ADA Dental Claim Format

Dentists do not bill on a CMS form. They use the ADA Dental Claim Form, built by the American Dental Association for easy review by dental payers. It runs on paper or as an electronic flat file that mirrors its boxes.

Key details the form captures:

• Patient facts. Full name, birth date, address, policy or group number.
• Provider identity. Dentist’s name, NPI, practice address, phone, and pay‑to number.
• Service codes. Each procedure uses a CDT code (e.g., D1110 for adult cleanings).
• Tooth data. The form shows tooth numbers, surfaces, and quadrants to prove need.
• Clinical notes. A short box lets you add a narrative. This is beneficial for crowns, implants, or ortho claims because payers need clear proof of medical need (cracks, bone loss, malocclusion) before they sign off on these higher‑cost services.

Why this dental format matters?

• Uniform language. CDT codes and tooth charts let payers price claims fast.
• HIPAA alignment. The form meets HIPAA‑compliant medical claim format rules and maps straight to the 837D EDI file.
• Low denial risk. *Clear tooth surfaces and dates stop “lack of info” rejections that delay checks.

4). the Workers’ Compensation Claims Format

When an injury happens on the job, the claim does not go through a regular health plan. Instead, you bill the employer’s workers’ comp carrier in a special healthcare claims format that mixes state rules with HIPAA data sets.

What format are workers’ comp claims submitted in?

• Paper route. Many carriers still ask for a CMS‑1500 marked “Workers’ Compensation” in Box 10 d. Attach state‑required injury reports and mail the bundle to the adjuster.
• Electronic route. Larger payers accept an ANSI X12 837P or 837I file plus the state’s claim number in Loop 2300. This meets HIPAA‑compliant medical claim format rules while flagging the file as work‑related.

Either way, use the standard format for submitting medical claims. But add the extra comp fields listed below so the adjuster can link services to the injury event.

Must‑have fields that keep the claim moving:

• Employer data. Full company name, address, and the workers’ comp policy number prove coverage.
• Employee facts. Name, home address, birth date, and Social Security number pin the claim to one worker.
• Injury snapshot. Date, time, and place of the accident, plus a short injury story (e.g., “strained lower back lifting boxes”).
• Service lines. List each CPT® or HCPCS code, tied to ICD‑10‑CM trauma codes (S‑ and T‑series) that match the injury note.
• Claim number. The state or carrier issues this after the first report of injury. Put it on every claim so payment flows to the right file.

5). the Coordination of Benefits Claim Format

Patients who have two or more health plans need a clear hand‑off. That hand‑off happens in the Coordination of Benefits (COB) claim format—the fields inside every paper and electronic claim that tell payers who pays first and who pays next.

“Who pays first” means the primary plan—the policy that has the legal duty to process the bill before any other insurer. It allows or denies each charge, applies its own deductible or copay rules, and sends an Explanation of Benefits (EOB) that shows what it paid and what is still owed.

“Who pays next” refers to the secondary (or tertiary) plan. This plan cannot act until it sees the primary EOB. Once it has that record, it:

• checks the remaining balance,
• pays up to its own benefit limits, and
• may wipe out the left‑over patient share.

Example: A patient has an employer health plan and is also covered under a spouse’s plan. The employer plan is primary, so it handles the claim first. After it posts payment, you transmit the same claim—with the primary paid amount filled in—to the spouse’s plan. That plan is secondary and can now cover some or all of the leftover cost.

Stating this order in the COB claim format keeps every payer in line with federal Coordination‑of‑Benefits rules, stops over‑payment, and ensures the patient never gets billed twice for the same care.

When someone asks “in what format are healthcare claims sent when the patient has double coverage?” the answer is: CMS‑1500 or UB‑04 on paper, and ANSI X12 837 with COB loops on EDI.

What the COB data must show?

➜ Each policy in plain view

• Insurance name, plan type, and policy number
• Start and end dates so the payer sees the coverage line‑up

➜ Benefit check

• Does the plan pay primary or secondary on this visit?
• Any carve‑outs or limits that change how much it will cover

➜ Payment order

• You mark the primary carrier first, the secondary carrier second, and so on
• In an 837 file, this sits in Loop 2320—HIPAA’s built‑in spot for COB rules

Why the COB format cuts claim ping‑pong?

• Stops over‑payment. Clear policy data keeps payers from paying more than the charge.
• Speeds split‑payment. When the primary plan’s paid amount drops into the secondary plan’s field, the second payer can finish the bill without calling you.
• Meets every rule. COB elements sit inside the same HIPAA‑compliant medical claim format you already use, so you stay within federal privacy guardrails.

6). the Medicare and Medicaid Claim Form Formats

Federal payers follow strict layout rules. When you bill Medicare or Medicaid, you choose the claim format first, then you fit every field to the CMS guide.

Pick the right form or its EDI twin:

• CMS‑1500 / 837P – Use this medical claim format for professional work: office visits, lab draws, therapy, ambulance runs.
• UB‑04 / 837I – Use this format for facility fees: hospital stays, rehab days, dialysis, outpatient surgery.

Think of the paper form as a picture of the electronic file. The boxes on the page map line-for-line to the segments in the ANSI X12 file. That link keeps each claim HIPAA-compliant and easy to read by Medicare’s edits.

Key Medicare-Medicaid format rules:

• Use the right code sets. Stick to ICD‑10‑CM for the “why,” CPT®/HCPCS for the “what,” and revenue codes for room and board.
• Show the NPI every time. Place your ten-digit NPI in the provider ID box and in Loop 2010AA of the 837 file.
• Add the payer ID. Medicare uses payer ID “CMS.” State Medicaid plans list their own four- or five-character IDs—check your remittance advice if you forget.
• Lock the date style. Medicare denies claims with slashes. Enter dates as MMDDYYYY on paper and as CCYYMMDD in EDI.
• Include signature on file. On the CMS‑1500, mark “Signature on File” in Box 12 and Box 13. In the 837P use the HI segment flag. This shows you hold the patient’s consent.

Electronic Claim Formats

Manual Claim Formats

FAQs

What is primary and secondary insurance?

Primary insurance is the first plan that reviews your claim and pays up to its own benefit limits. Secondary insurance steps in after the primary issues an Explanation of Benefits (EOB) and covers some or all of the leftover bill. Clear COB data on your claim tells payers in what order to pay.

What is the difference between a claim form and a claim format?

Form = a paper document (CMS-1500, UB-04, ADA) you print, sign, and mail or fax.
Format = an electronic data file (837P, 837I, 837D, NCPDP) you send through EDI. Each format mirrors its paper twin and meets all HIPAA-compliant medical claim format rules.

What is the CMS-1500 form used for?

Providers submit professional services—office visits, therapy, lab draws—on the CMS-1500 paper claim form when electronic filing is not an option.

What is the UB-04 form used for?

Hospitals, rehab centers, and skilled-nursing homes bill inpatient stays and other facility fees on the UB-04 (also called CMS-1450) when a payer still requires paper.

What does the 837P format represent?

The 837P is the electronic medical claim form format that replaces the CMS-1500. It travels by HIPAA-secure EDI and speeds professional claim processing.

How does the 837P differ from the 837I?

The 837P carries professional claims (outpatient visits, ambulance runs). The 837I carries institutional claims (inpatient room charges, outpatient surgery). Both follow the ANSI X12 healthcare claims format.

Why do most payers prefer electronic submission?

Electronic claims reach payers in seconds, cut keystroke errors, and meet every healthcare claim submission format requirement under HIPAA. Faster in, faster paid.

What is EDI in healthcare billing?

Electronic Data Interchange (EDI) is the secure network that moves 837 claim files, 835 remittances, and 270/271 eligibility checks between providers and payers.

Can I still use paper claim forms under HIPAA?

Yes. Smaller clinics and some state programs may mail claims. Yet most carriers now ask, “in what format are healthcare claims sent?”—and expect the electronic answer. Submitting the correct electronic claim format (837P, 837I, 837D, or NCPDP) speeds payment and keeps you compliant.

How can a medical billing service help with claim submission and denial management?

A medical billing services company knows every healthcare claims format inside out. It scrubs your data before you send a CMS-1500, UB-04, 837P, or 837I, catching code or NPI errors that cause denials. The team transmits each claim through its own high-speed clearinghouse link, tracks the payer’s edits in real time, and fixes any rejections the same day. When a denial does occur, the service applies denial management best practices and pulls the EOB, adds the missing detail, files an appeal, and resubmits in the proper claim submission format (often within 24 hours).

This can happen for many reasons. You might miss some patient information. A code might be wrong. Or no one followed up with the payer. No matter the cause, delayed claims create problems. They hurt your cash flow, frustrate your patients, and add stress to your team.

Here’s the good news: most delinquent medical claims are easy to prevent. With the right systems and a few simple habits, you can keep your billing on track.

In this blog, you’ll learn how to avoid claim delays, get paid faster, and keep your practice running smoothly.

What Is a “Delinquent” Claim?

Before we talk about prevention, it’s important to understand what a delinquent claim actually is.

A delinquent claim is a health insurance claim that hasn’t been paid by the insurance payer to the healthcare provider within the expected timeframe. For most payers:

• Electronic claims are expected to be paid within 30 days
• Paper claims usually have up to 45 days

These timelines apply across most commercial insurers, as well as Medicare and Medicaid.

To meet these deadlines, healthcare providers must move quickly and accurately—from patient registration, through coding, to final claim submission. But if anything in this process is missed or delayed, the claim may not get paid on time.

If a payer doesn’t send payment within their expected window, the claim becomes delinquent. At this point, either the provider’s in-house billing staff or their outsourced medical billing company must take action. This could involve:

• Reviewing the claim for missing modifiers or CPT/ICD-10 coding errors
• Confirming the claim was received by the payer or clearinghouse
• Resubmitting the claim, if necessary

It’s important to note: a delinquent claim is not the same as a denied claim. The claim may still be “processing,” placed “on hold,” or delayed due to something as simple as an incorrect payer address or a missing document.

When a Claim Becomes Delinquent?

A claim becomes delinquent when it:

• Is at risk of being denied, written off, or sent to collections
• Has been unpaid beyond 30 days (for electronic claims) or 45 days (for paper claims), depending on the payer
• May be held up due to missing information, errors, or payer issues

Impact of Delinquent Claims

When a claim drags past its due date, three parties feel the impact — your medical practice, the payer, and the patient. Here’s the clear, step‑by‑step chain of events.

Stage 1 – Claim Sits in A/R (Day 0 – 30)

	Details
Trigger — Why it happens	Claim is submitted but pends or denies for data, coding, or eligibility errors.
What your team does	Biller edits the claim, rebills, and calls the payer for status.
What actually happens	Cash that should arrive in 14 days now sits in Accounts Receivable (A/R).
Who feels it	Practice leadership — KPIs such as “days in A/R” climb, squeezing cash flow.

Stage 2 – Patient Becomes the Payer (Day 31 – 60)

	Details
Trigger — Why it happens	Payer downcodes or denies the service. Your policy shifts the balance to “patient responsibility.”
What the patient sees	A surprise bill (e.g., $300) appears in the mailbox or portal.
What actually happens	Confused patients delay payment, waiting for “another insurance adjustment.” After 60 days a $25 late fee applies.
Who feels it	Patient – shock and frustration. Practice – still no cash, clerical load rises.

Stage 3 – Collections Take Over (Day 61 – 120)

	Details
Trigger — Why it happens	Patient ignored at least two statements and a final notice. Your financial policy—signed at intake—sends ≥ 60‑day accounts to collections.
What the agency does	Calls or texts the patient up to three times a week; adds a 15–20 % fee (e.g., $325 → ≈ $390); offers payment plans.
Who feels it	Patient – stress grows with every call. Practice – online reviews blame your clinic, not the agency, eroding trust.

Stage 4 – Credit Report Damage (Day 180 +)

	Details
Trigger — Why it happens	Unpaid balance > $500 remains in collections for 180 days. Agency reports it to Experian, Equifax, and TransUnion.
What actually happens	Credit score may drop 50–100 points.
Who feels it	Patient – faces higher loan rates and may skip follow‑ups. Practice – loses revenue from missed care.

Stage 5 – Lawsuit & Public Record (Month 6 – 18)

	Details
Trigger — Why it happens	Large balances (often >$2,000) remain unpaid; hospitals or debt buyers sue in states like New York, Texas, or California.
What the court does	Adds filing fees, attorney costs, and may approve wage garnishment. Case becomes public record.
Who feels it	Patient – faces legal risk and long‑term credit damage. Practice – name appears in court documents, signaling harsh collections—even if the root cause was a preventable claim error.

How to Prevent Delinquent Medical Claims?

Delinquent medical claims aren’t just an inconvenience — they directly threaten your revenue flow.

When claims aren’t paid on time, it creates a domino effect of rework, patient confusion, lost revenue, and wasted hours chasing down answers.

The good news? Most of it’s preventable.

Here’s how healthcare practices can prevent claims from going delinquent, improve cash flow, and reduce stress.

1). Get It Right at the Front Desk

The front desk may not stamp invoices, yet it controls every data element a payer will judge. One mistyped policy number or an expired plan on file can trigger a denial that costs weeks of rework.

• Verify insurance at every visit. Run a real‑time eligibility (RTE) check before the patient sits down.
• Scan IDs and cards. Store both sides in the EHR for instant reference.
• Confirm spelling aloud. Catch name or date‑of‑birth errors while the patient can still correct them.

2). Scrub Every Claim Before Submission

Claim scrubbing is a second set of eyes—only faster. By auto‑flagging code mismatches in seconds, you stop denials before they enter the payer’s system.

• Pass every encounter through a clearinghouse. Let software spot CPT/ICD‑10 conflicts, missing modifiers, and NPI errors.
• Fix alerts on the spot. Aim for a 97 percent or better clean‑claim rate.

3). Monitor Submitted Claims Actively

A claim can disappear into a payer queue, gathering dust while the filing clock keeps ticking. Real‑time monitoring surfaces silent claims early, so you can nudge them before they stall out.

• Set status alerts. Flag any claim that shows no movement after 14 days.
• Run daily aging reports. Assign each silent claim to a staff owner for follow‑up.

4). Follow Up Early — Not After It’s Too Late

Denials aren’t death sentences; they’re calls to action. A tight, seven‑day appeal cycle converts many of them into full reimbursements—long before they qualify as delinquent.

• Route denials by reason code. Coding, medical necessity, eligibility, and prior auth each get a separate queue.
• Appeal within seven calendar days. Include corrected codes, notes, and supporting records in one packet.

5). Patient Financial Engagement

Patients pay faster when they know exactly what they owe and have friction‑free ways to settle up. Transparent, tech‑friendly billing keeps their balances from aging into collections.

• Send e‑statements the day a balance posts and follow up with a text reminder.
• Offer no‑interest payment plans for balances over $200.
• Publish estimates and financial‑assistance options online and at check‑in.

6). Create a Denial Management Workflow

Denied claims are the biggest gateway to delinquency—unless you treat them with factory‑grade precision. A clear playbook turns firefighting into an orderly, repeatable process.

• Categorize denials (coding error, prior auth, eligibility, medical necessity).
• Prioritize high‑dollar, appealable claims.
• Rework and resubmit within five to seven days.
• Track root causes so one fix can eliminate dozens of future denials.

7). Use a Centralized Claims Dashboard

Spreadsheets hide patterns; dashboards reveal them. A single, color‑coded view of every claim lets your team tackle the oldest and riskiest accounts first—before they slip past timely‑filing limits.

• Show total outstanding claims with aging buckets (0–30, 30–60, 60–90, 90+).
• Highlight payer bottlenecks and denials awaiting action in real time.

8). Keep the Whole Team Informed

Your coders, clinicians, and front‑desk staff all leave fingerprints on a claim. Regular knowledge‑sharing keeps small mistakes from snowballing into systemic cash delays.

• Hold a monthly revenue‑cycle huddle. Bring front desk, coders, billers, and providers together.
• Share payer rule changes and new denial trends.
• Coach clinicians on documentation gaps that trigger “medical necessity” denials.

9). Automate Where You Can

Manual keystrokes breed errors and burnout. Automating routine tasks frees your staff to focus on higher‑value work like appeals and patient calls.

• Automate eligibility checks, claims submission, denial alerts, aging reports, and balance reminders.
• Integrate RCM and EHR systems to eliminate double entry.

10). Build a Claims Quality Checklist

A simple checklist is a tiny time investment that prevents month‑long payment delays. Think of it as your claim’s boarding pass—no errors, no hold‑ups.

• Insurance verified
• CPT and ICD‑10 codes match
• Modifiers and prior‑auth included
• Claim passed scrubber
• Correct payer ID

11). Don’t Miss Timely Filing Deadlines

Payers don’t negotiate filing deadlines. Miss one and the revenue is gone—appeals included. Rigorous deadline tracking keeps every claim alive until it pays.

• Catalog each payer’s limits (e.g., 90 days, 180 days).
• Flag claims 30 days before expiration for urgent follow‑up.
• Apply the same countdown to denials; resubmit well before cutoff.

Conclusion

Take last month’s aging report, grab a marker, and swipe every claim older than 30 days. Jot a quick note beside each one (missing code, no authorization, wrong ID) whatever tripped it. When the same problem shows up twice, that’s your fix for the week. Give it five days; if the payer still hasn’t moved, get a live rep on the phone. Do this every week and slow‑pay surprises lose their punch before they drain your cash or your team’s patience.

The Office of Inspector General (OIG) has updated its 2025 Work Plan and is focusing on reviewing postoperative services that are part of the global surgery period. With the recent changes in the global surgery coding system for 2025, it’s essential for healthcare professionals to stay up-to-date.

The OIG (Office of Inspector General) is examining how these postoperative services are being provided and billed during the global surgery period. This could involve checking for compliance, accuracy in billing, or identifying issues like overbilling or lack of quality of care.

For healthcare providers, it is important to understand the 2025 global surgery updates as it could impact their practices of documenting the surgery procedures and billing for services. However, for patients it is also vital as it lets them receive proper care during the recovery period and improve transparency.

This guide will help you walk through the new coding requirements, postoperative services, and how to comply with Medicare regulations. But, first let’s discuss the global surgical period.

What Is a Global Surgery Package?

A Global Surgery Package, also known as global surgery or the global period is a Medicare concept where payment for a surgical procedure includes the surgery itself and related services provided before, during, and after the surgical procedure. These services are bundled into a single payment, covering preoperative visits, the surgical procedure, and postoperative care (follow-up visits) within a specified time frame usually ranging from the day of surgery to 10 or 90 days after the surgery.

If providers in the same group and specialty are involved in the surgical procedure, they must submit their bills and accept payment as if they’re one provider. This keeps billing simple and avoids double charges.

Global Surgery Package Duration and Procedure Types

CMS Guidelines for Global Surgery Period—What Is Included in The Global Surgery Package?

For Medicare claims, CMS (Centers for Medicare & Medicaid Services) includes the following services in the global surgery payment:

• Preoperative Visits
• Intraoperative Services
• Other Medical or Surgical Services in the Postoperative Period
• Postoperative Follow-Up Visits
• Post-Surgical Pain Management
• Supplies
• Miscellaneous Services

Preoperative Visits

These are visits that happen after the decision to operate has been made during the evaluation and management process (E/M). This includes minor surgeries or endoscopy procedures performed by the same provider on the same day as the surgery.

Intraoperative Services

These are services provided during the actual surgery, including everything necessary to perform the surgical procedure.

Other Medical or Surgical Services in the Postoperative Period

All other medical or surgical services after the surgical procedure include any additional medical or surgical care that the surgeon provides to the patient during the designated recovery time after the surgery.

Postoperative Follow-Up Visits

These are check-ups or follow-up appointments to monitor the patient’s recovery during the postoperative period. Usually the code 99024 is used to track the follow-up visits. 

Post-Surgical Pain Management

Post-Surgical Pain Management includes care provided to help the patient manage pain after the surgery, such as medication or therapy.

Supplies

These are materials used during the surgery and recovery period, except for certain excluded items. For example, bandages or surgical tools.

Miscellaneous Services

These are smaller, routine tasks related to surgery, such as bandage changing, local incision care, operative pack removal, cutaneous sutures and staples removal, etc.

CMS guidelines for global surgery Period— What Isn’t Included in the Global Surgical Package?

Here are certain services that CMS does not include in the global surgical package, and what providers can bill separately and get paid.

• Initial Evaluation for Surgery
• Services by Other Providers
• Unrelated Visits
• Treatment for Separate Health Conditions
• Diagnostic Tests
• Additional Surgeries
• Complication Treatment in OR (Operating Room)
• Failed Minor Procedure Leading to Major Surgery
• Organ Transplant Medications
• Critical Care Services

Initial Evaluation for Surgery

The surgeon’s decision on the first visit to evaluate if major surgery is needed is not part of the global surgical package. The evaluation visit (E/M) can be billed separately using modifier 57.

Services by Other Providers

If other providers (not the surgeon) perform surgery-related services, these are excluded from the package unless there’s an agreement to transfer care between the surgeon and other providers. This agreement must be documented in the patient’s medical records.

Unrelated Visits

Follow-up visits for conditions unrelated to the surgery or its diagnosis are not included in the global surgery package, except when visits are due to surgery complications.

Treatment for Separate Health Conditions

If a patient needs treatment for an underlying or unrelated health condition, or begins a new treatment unrelated to surgery recovery, it’s billed separately.

Diagnostic Tests

Tests or procedures to diagnose issues (like X-rays or other scans) are not included in the package and require separate billing.

Additional Surgeries

Surgeries performed during the recovery period that are not part of the original surgery or related to surgery complications are excluded from the Medicare global surgery package. 

Complication Treatment in OR (Operating Room)

If the patient needs to return to the OR for postoperative complications, the treatment is billed separately.

Failed Minor Procedure Leading to Major Surgery

When a less serious surgery doesn’t work and a major surgery is needed, Medicare covers the major surgery separately.

Organ Transplant Medications

Medications used to manage the immune system after an organ transplant are not part of the global surgical package.

Critical Care Services

Critical care provided (CPT codes 99291 and 99292) after surgery for issues unrelated to the surgical procedure is excluded. These services should be billed separately using modifier FT.

2025 Global Surgery Updates

The 2025 global surgery package updates bring key changes, including the introduction of HCPCS code G0559, which is used for postoperative follow-up visits provided by a different healthcare professional who didn’t perform the surgery, within the 90-day global period, and without a formal transfer of care.

Modifiers 54, 55, and 56 are now more strictly required for managing preoperative, surgical, and postoperative care within 90-day global packages, with modifier 56 now requiring formal documentation for preoperative care transfers.

The updates also focus on the Office of Inspector General’s (OIG) review of postoperative services, ensuring proper reporting and preventing overreporting of services during the global period. These updates aim to improve billing practices and ensure accurate Medicare reimbursement for global surgeries.

The Role of the OIG and CMS in Global Surgery Coding 2025

The Office of Inspector General (OIG) is investigating how well postoperative services are reported under Medicare’s global surgery payment system. Since July 1, 2017, Medicare requires healthcare providers to report follow-up visits after surgery using a specific code, CPT code 99024. This code is for postoperative visits where the doctor checks the patient’s recovery after surgery.  Although these visits are part of the global period and aren’t paid separately during the global period, reporting them helps Medicare track how often patients need follow-ups after surgery.

Here is when providers have to report postoperative visits using code 99024 under specific conditions:

• Practitioners in certain states (like Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, Rhode Island) who work in groups with 10 or more practitioners.
• Providers in those states need to check a list from Medicare each year to see if their surgeries are on the list of surgeries that need the code.
• This code applies only to specific types of surgeries or procedures. These procedures are selected by Medicare because they are either very common (performed over 10,000 times a year) or very expensive (with charges over $10 million a year).

The OIG (Office of Inspector General) is monitoring that doctors are reporting these follow-up visits correctly. They will look at a sample of global surgeries, compare the number of follow-up visits in the CMS records with what doctors reported to Medicare, and verify if the payments made for the surgeries match the actual care provided to Medicare beneficiaries. If doctors don’t report this information properly, it could lead to Medicare paying less for those surgeries. If providers don’t report this information properly, it could lead to devaluation of the Medicare global surgery payment.

Basically, Medicare wants to check the follow-up visits after surgery are being properly tracked, and if doctors aren’t reporting them correctly, it might affect their payment.

Importance of Using Modifiers During Global Surgery Period 

Sometimes, a patient may need other procedures that aren’t related to the surgery they just had, but these procedures still happen during the global period. The usage of global surgery modifiers (24, 25, 54, 55, 57, 58, 78, 79, FT) facilitate healthcare providers to get paid for these services. These modifiers are used to separate unrelated procedures from the global surgery, so they can be paid for separately, even if they happen during the global period.

In the Medicare Physician Fee Schedule (MPFS), there are certain payment policy indicators that show which services are billable (can be paid for) and whether a modifier is needed.

Some examples of global modifiers include:

• Modifier 24: Used for services unrelated to the surgery but happening during the global period.
• Modifier 25: Used for an unrelated service provided on the same day as the surgery.
• Modifiers 54, 55, 57, 58, 78, 79: Indicate different situations where services are not included in the global period.
• Modifier FT: Used for specific cases defined by Medicare.

➜ Modifiers 24

Modifier 24 is used when a doctor or healthcare provider performs unrelated evaluation and management (E/M) service. These services must be after the procedure but within the global period and are unrelated to the original surgical procedure.

For example:

On March 10, a patient visits their orthopedic surgeon for a knee arthroscopy (CPT 29881), which has a 90-day global period. On March 15, the patient returns to the same surgeon, complaining of new back pain unrelated to the knee surgery. The surgeon evaluates the patient’s back condition and recommends physical therapy for the back pain. Since this visit is not related to the knee arthroscopy, the surgeon will code the appropriate office visit E/M code with modifier 24. This allows the surgeon to be separately paid for the back-pain evaluation, even though it falls within the global period for the knee surgery.

➜ Modifier 25

This modifier is used when the same physician or other qualified healthcare professional performs a significant, separately identifiable evaluation and management (E/M) service on the same day as a procedure or other service.

For example:

A patient arrives at the doctor’s office on the same day they are scheduled for gallbladder removal surgery (CPT 47562 – Laparoscopic Cholecystectomy). During the pre-surgery evaluation, the doctor notices that the patient has significantly high blood pressure. The doctor spends extra time assessing the patient’s blood pressure, determining the cause, and prescribing immediate medication to stabilize the patient before proceeding with surgery.

In this case, the additional evaluation and management (E/M) service for high blood pressure is beyond the usual preoperative care related to the gallbladder surgery. The doctor can use Modifier 25 to bill separately for the extra E/M service.

➜ Modifier 57

Use of Modifier 57 indicates that a decision for surgery was made during an evaluation and management (E/M) service, and that the decision occurred on the same day as the E/M service. This modifier tells the payer that the E/M visit led to a decision for surgery, and because the decision was made during the same visit, the surgery is being reported separately from the usual preoperative care.

For example:

A patient arrives at the emergency room (ER) after experiencing severe abdominal pain. The ER physician performs an evaluation and determines that the patient may have acute appendicitis. After a thorough examination and some tests, the physician discusses the situation with the patient and recommends immediate surgery to remove the appendix.

The decision for surgery is made during the evaluation and management (E/M) service in the ER. The patient is then taken to the OR on the same day for an appendectomy (removal of the appendix).

Since the decision for surgery was made during the E/M service on the same day, the ER physician uses Modifier 57 when reporting the E/M code. This modifier indicates that the E/M visit led directly to the decision for surgery, which occurred on the same day.

➜ Modifier FT

Using Modifier FT indicates an unrelated evaluation and management (E/M) visit during a postoperative period or on the same day as a procedure or another E/M visit. The key aspect here is that the E/M service is unrelated to the procedure that was performed or is planned, and it may be billed separately. This modifier applies when an E/M service is provided that is unrelated to the surgery or procedure performed on the same day or within the global surgical period. It is particularly relevant when a patient requires critical care during the postoperative period, which is unrelated to the surgery.

For example:

A patient undergoes gallbladder surgery (CPT® 47562) on March 10. On the same day, the patient develops a severe allergic reaction unrelated to the surgery, requiring urgent treatment and evaluation. The physician uses Modifier FT to report the E/M service provided on March 10 for the allergic reaction as unrelated to the gallbladder surgery. This ensures the physician gets reimbursed for both the surgery and the unrelated E/M service provided on the same day.

Procedural Modifiers 54, 55, 56

Modifiers 54, 55, and 56 are used to split reimbursement between two different healthcare providers when the surgical procedure and preoperative/postoperative care are managed by separate physicians. This is often referred to as a “transfer of care” and helps ensure that both the surgeon and the other providers (such as a primary care physician) are appropriately reimbursed for their role in the patient’s care.

• Modifier 54 (Surgical Care Only)

Modifier 54 is used by the surgeon who performs the surgery but does not provide preoperative or postoperative care.

• Modifier 55 (Post-Operative Management Only)

Modifier 55 is used by the physician or provider who takes over post-operative care after the surgery is completed. It applies when the provider does not perform the surgery but manages the recovery phase instead. After a surgery is performed in one hospital, the patient may be transferred to a different location, and a different physician will provide follow-up care for the post-operative recovery period.

• Modifier 56 (Pre-Operative Management Only)

This modifier is used when the physician or provider who manages the preoperative care of the patient. It applies when the provider does not perform the surgery but is responsible for preparing the patient before the surgery, such as clearing them for anesthesia or managing their health conditions. For example, a primary care provider may ensure the patient is ready for surgery, while a different physician performs the procedure.

These modifiers are used when two different healthcare providers (such as a surgeon and a hospitalist or a primary care physician) are involved in a patient’s surgical care, especially when the care is split between preoperative, surgical, and postoperative periods.

According to 2025 global surgery updates, CMS will require these modifiers for all 10 to 90-day global surgical packages, ensuring accurate reimbursement for each phase of surgical procedure.

For example:

A patient comes to the ER with a dislocated shoulder. The ED physician performs a closed reduction and reports the procedure with Modifier 54 for surgical care only. The patient is then referred to an orthopedic specialist for postoperative care, and the orthopedic doctor reports the same procedure code with Modifier 55. If the patient had seen a primary care provider (PCP) before the surgery for preoperative management, the PCP would have reported their care with Modifier 56 for preoperative care only. All providers use the same date for the procedure on their claims.

➜ Modifier 58

Adding modifier 58 indicates that a staged or related procedure was performed by the same physician (or other qualified healthcare professional) during the post-operative period of a previous procedure. This modifier specifies that the new procedure or service is planned, expected, or necessary due to the patient’s condition and is related to the initial surgery. Modifier 58 resets the global period, starting a new one for the next procedure.

For example:

A patient undergoes a knee replacement surgery. As part of the surgical plan, the surgeon schedules a follow-up arthroscopic procedure to inspect and adjust the placement of the knee prosthesis after the initial healing phase. This follow-up procedure is planned in advance and is related to the initial surgery. When the patient returns during the global period of the knee replacement for the planned arthroscopic procedure, the surgeon reports the follow-up procedure with Modifier 58 to indicate that it is a staged and related procedure.

➜ Modifier 78

Modifier 78 is used for an unplanned return to the operating room when a patient requires a related procedure during the postoperative period due to complications from the initial surgery, such as infection or bleeding. This modifier indicates that the same physician, or a healthcare professional from the same specialty group, performs the second procedure to address the issue. The second procedure is considered part of the original surgery and does not start a new global period. For repeat procedures, Modifier 76 should be used. 

For example:

During the global period of a surgery, the patient experiences excessive bleeding, requiring the surgeon to return to the operating room to control it. This procedure is reported with Modifier 78 to indicate it is an unplanned related procedure performed during the postoperative period.

➜ Modifier 79

Modifier 79 is used when a physician performs an unrelated procedure or service during the postoperative period of a prior surgery. This procedure is not related to the initial surgery and must be billed separately, as it is not covered by the original surgery’s global package. If a procedure is repeated on the same day, Modifier 76 should be used.

For example:

On March 5, a patient undergoes knee replacement surgery on the right leg. On April 5, the patient undergoes the same surgery on the left leg. Even though it’s the same procedure for the same diagnosis, the surgeries are performed on two different surgical sites, making them unrelated. Modifier 79 is appended to the medical code for the surgery on April 5 to indicate it is a separate, unrelated procedure performed during the postoperative period of the first surgery.

Best Practices for Global Surgery Coding Compliance

By following these best practices, healthcare providers can stay compliant with global surgery coding requirements:

Use Proper Documentation

• Keep complete and accurate documentation for all care services provided before, during, and after the surgical procedure.
• Maintain clear records for transfer of care, especially when other providers are involved in preoperative, surgical, or postoperative care.

Know the Global Surgery Period

• Understand the global surgery period for each surgical procedure and apply it correctly. For example, some procedures may have a 10-day, 90-day, or 0-day global period as explained in the table above.
• Review the global surgery indicators assigned to each procedure (e.g., 000, 010, 090) to confirm the global period for billing purposes.

Use Proper Modifiers

• Use the correct modifiers when services are provided that are outside the scope of the global surgery package.

Properly Apply HCPCS Code G0559

• According to the 2025 global surgery period, use HCPCS code G0559 for post-operative follow-up visits by a healthcare provider who did not perform the surgery, and there was no formal transfer of care.

Review Medicare Physician Fee Schedule (MPFS)

• Check the MPFS for global surgery package indicators (e.g., 000, 010, 090) and understand the rules for each CPT code.

Comply with OIG Guidelines

• Adhere to Office of Inspector General (OIG) requirements for reporting postoperative services, especially for evaluation and management (E/M) services.
• Use CPT code 99024 for postoperative E/M visits where required, particularly in states that require reporting for global surgeries.

Accurate Reporting of Postoperative Care

• Report only care services that are directly related to the original surgical procedure. Do not report services outside of the global package unless they are unrelated or involve complications.
• If a procedure or service is unrelated to the original surgery, apply the correct modifier (e.g., modifier 79).

Provide Transfer of Care Documentation

• Document formal transfers of care when the patient’s care is transferred between providers, especially for preoperative and postoperative care.
• Use modifier 56 for preoperative services and modifier 55 for postoperative services when the care is performed by different providers.

Stay Updated on CMS and OIG Changes

• Regularly review updates from CMS and the OIG to stay compliant with new coding guidelines or updates as they released global surgery period 2025 updates, such as the use of HCPCS code G0559 for postoperative follow-up visits.

FAQs

If you’re in healthcare, your license plate can do the same—and then some. It’s not just a boring combo of numbers and letters; it’s your own little billboard to show off your personality and profession.

Picture this: you’re driving along, and your plate proudly flaunts your medical vibes. Whether you’re a doctor, nurse, surgeon, or still grinding through med school, a custom license plate lets you celebrate your love for healthcare in a fun, one-of-a-kind way.

In this blog, we’re diving into a bunch of creative license plate ideas for every type of healthcare pro—from the general docs keeping us well to the specialists tackling the toughest cases. Stick around to snag your perfect plate idea or spark some inspiration of your own!

Why a Customized Medical License Plate Matters?

A custom license plate lets healthcare providers show off their passion for medicine in a fun, unique way. Here’s why it’s worth it:

Show Pride and Personality

A medical-themed plate reflects who you are—whether you’re a physician with a punny streak or a nurse with a sense of humor. It’s a small, proud nod to the difference you make daily.

Connect with Others

Spot a fellow medical practitioner with a similar plate? Instant bond. Even patients or passersby might feel a connection, knowing you’re part of their healthcare team.

Raise Awareness

Your plate can highlight causes you care about—like “HEART MD” for heart health—sparking interest without saying a word.

Inspire Future Healers

A plate like “FUTURE MD” could motivate a kid to dream big about a healthcare career. You’re a role model on the road!

Creative Medical License Plate Ideas By Category

Here’s a complete list of medical license plate ideas organized by profession and specialty. Whether you are searching for something serious or funny, there’s a variation for everyone.

a). Doctor and Physician License Plate Ideas

If you are a doctor or a general physician in any state of the USA – these license plates offer a unique way to customize your vehicle. See the following plate ideas:

1). HEALER

Simple yet powerful, “HEALER” tells the world what you do best—bring health and hope to your patients. Imagine pulling into the hospital parking lot with this on your car—it’s an instant badge of honor for your commitment to healing.

2). MEDLIFE

Short for “Medical Life,” this one’s for anyone whose world spins around healthcare (and isn’t that most of us in this field?). It’s catchy, quick, and screams, “This is who I am!”—perfect for showing off your medical pride.

3). SAVEME

Here’s a clever twist: “SAVEME” nods to the urgency of your work and the lives you save every day. It’s bold, it’s memorable, and it’s a little reminder to everyone on the road just how essential you are.

4). RXJXT4U

This one’s got some flair! “RX” stands for prescription, “JXT” adds a playful vibe, and “4U” means “for you.” It’s like saying, “I’ve got the perfect fix for you!”—a lighthearted way to flex your expertise.

5). DOC4UYO

“DOC4UYO” (Doc for You) is straightforward with a personal touch. It’s all about letting people know you’re there for them, ready to help whenever they need it. Simple, sweet, and to the point.

6). CAREGVR

With “CAREGVR,” you’re putting the spotlight on what really matters—caring for others. It’s a warm, inviting choice for any healthcare pro who wants to highlight the heart behind their work.

7). ICU4UEM

This one’s a brain teaser: “ICU” for Intensive Care Unit, plus “I See You for You.” It’s a creative way to show you’re all in when it comes to giving patients the intense, focused care they need in tough times.

8). DR2BSN

Got a medical student or resident in the house? “DR2BSN” (Doctor to Be Soon) is your pick! It’s a fun shoutout to the grind and dedication it takes to get that white coat—wear it proud!

b). Nurse Medical License Plate Ideas

Nurses are at the back of the whole healthcare sector. Therefore, give your profession value with heart and soul by making nurse-themed plates. Here are a few examples of these themed plates:

9). RN4EVER

RN4EVER is like a big, proud shout: “I’m a nurse for life!” It’s perfect if nursing isn’t just your job—it’s who you are. This plate shows everyone your love for the gig and that you’re in it for the long haul. It’s all about that forever commitment to making a difference.

10). NURSEUP

NURSEUP is your little pep talk on wheels! It’s there to cheer you on, reminding you to stay strong and upbeat even when the days get rough. Nursing takes grit, and this plate celebrates your determination and inner power. It’s like a high-five for getting through those tough shifts.

11). IVDRIP

IVDRIP is for the IV champs out there—you know, the nurses who can nail an IV line like it’s no big deal. It’s a fun way to say, “I’ve got skills!” If you’re the one everyone calls when the IV’s tricky, this plate lets you brag a little (in a good way, of course).

12). NRSHERO

NRSHERO is for the nurses who are straight-up heroes. You go the extra mile for your patients, and this plate’s like a badge of honor. It tells the world you’re not just doing a job—you’re saving the day, every day. It’s a simple, heartfelt nod to your bravery and care.

13). NRSLOVE

NRSLOVE is all about the heart of nursing. It mixes “nurse” and “love” to show how much you care for your patients. If you’re the kind of nurse who builds real connections and brings warmth to every room, this plate says it loud and clear. It’s a sweet, emotional way to share what drives you.

c). Surgeon Medical License Plate Ideas

Here are some creative and relatable license plate ideas for surgeons—perfect for skilled professionals who save lives in the operating room. These plates are a fun, personal way to showcase your expertise, dedication, and pride in your work. Each comes with a quick explanation to highlight what makes it special.

14). CUT4UA

CUT4UA is a bold way to say, “I’m a surgeon, and I make the cuts that save lives.” It’s a conversation starter that lets everyone know you’re proud of your skills in the operating room. This plate is perfect if you want to make a strong statement about the life-changing work you do.

15). ORPRO2

ORPRO2 is like a badge of honor for the operating room. It says, “I’m a pro in the OR, and I’m proud of it.” It’s a simple yet powerful way to show off your expertise and dedication to your craft. If you live for the intensity and precision of surgery, this plate’s for you.

16). FIXIT5

FIXIT5 is for the surgeons who love to solve problems. It says, “I’m here to fix what’s broken and help people get back on their feet.” It’s a nod to the hands-on, life-changing work you do every day—perfect for those who see surgery as both a skill and a mission.

17). STITCH

STITCH is a fun way to say, “I’m the one who puts everything back together.” It’s a lighthearted nod to the precision and care you bring to closing up after a surgery. If you’ve got a sense of humor about your role, this plate is a great way to show it.

18). SCALPEL

SCALPEL is a direct shout-out to the tool of your trade. It says, “I’m a surgeon, and I wield this instrument with skill and precision.” It’s a powerful way to highlight your dedication to your craft and the careful, steady hands that define your work.

Specialty-Specific Medical License Plates Ideas

We have more ideas for you if you want more specifications on your medical license plate. You can customize your plates according to your specialty. Here are some ideas for specialty-specific medical plates:

Pediatrics

Pediatrics is all about caring for the little ones, from babies to teens. If you’re a pediatrician, these plates are a sweet way to show your love for your tiny patients and let everyone know you’re the go-to doc for kids.

19). PEDIMD

PEDIMD is like wearing your heart on your sleeve—or in this case, on your car! It tells the world you’re a pediatrician who’s all about keeping kids healthy and happy. It’s a great conversation starter at the playground or school drop-off, and it’s an easy way to show your pride in your specialty.

20). LILDOC

LILDOC is just plain adorable. It’s a fun, playful way to say, “I take care of the little ones,” and it might even make your patients (and their parents) smile when they see it. If you want a plate that’s charming and full of heart, this one’s for you.

Cardiology

Cardiologists, you’re the heartbeat of healthcare! These plates let you show off your passion for keeping hearts healthy and strong while giving a nod to the life-saving work you do every day.

21). EKGMD

EKGMD is perfect for the cardio whiz. It says, “I know hearts inside and out,” and it’s a cool way to highlight your expertise with electrocardiograms (EKGs). If you’re the one reading those heart rhythms like a pro, this plate is a great fit.

22). PULSE

PULSE is simple but powerful. It’s a reminder of your role in keeping hearts beating steady and strong. This plate is a subtle yet meaningful way to celebrate the vital work you do.

Dermatology

Dermatologists, you’re the skin whisperers! These plates let you flaunt your expertise in keeping skin healthy and glowing, whether you’re treating a pesky rash or something more serious.

23). ACNEFX

ACNEFX is a fun way to show you’re the acne-busting hero. It’s like saying, “I’ve got the fix for clear skin,” and it’s sure to resonate with anyone who’s ever battled breakouts. If acne is your niche, this plate’s a great way to own it.

24). DERMDR

DERMDR is straightforward and proud. It tells the world you’re the skin doctor, ready to tackle everything from rashes to skin cancer. If you want a plate that’s professional but still personal, this one’s a winner.

Anesthesia

Anesthesiologists, you’re the unsung heroes of the operating room, making sure patients are comfortable and pain-free during surgery. These plates celebrate your crucial role in a fun and relatable way.

25). SLEEPDR

SLEEPDR is a cheeky nod to your ability to safely put patients to sleep during surgery. It’s a lighthearted way to show off your skills while keeping things fun. If you’ve got a sense of humor about your work, this plate’s a great pick.

26). ANESTH

ANESTH is clean and professional. It says, “I’m the one who makes sure surgery is a breeze,” and it’s a simple way to highlight your expertise in anesthesia. Perfect for those who want a plate that’s straight to the point.

Podiatry

Podiatrists, you’re the foot and ankle wizards! These plates let you strut your stuff and show your dedication to keeping people on their feet—literally.

27). ANKLDR

ANKLDR is perfect for the ankle expert. It’s like saying, “I’ve got your back—well, your ankles!” and it’s a great way to spotlight your specialty in treating ankle conditions like sprains, arthritis, or Achilles tendon issues.

28). TEODOC

TEODOC is playful and fun. It’s a lighthearted way to say, “I’m the toe doctor,” and it’s sure to bring a smile to anyone who sees it. If you want a plate that’s a little quirky and full of personality, this one’s for you.

Tips For Choosing the Perfect Medical License Plate

Selecting the right and perfect medical license plate is indeed a creative and enjoyable process! It’s a fantastic opportunity to showcase your profession with a dash of personality. Here are some tips to help you craft a customized license plate that reflects your medical career:

Check If It’s Available

First things first, make sure your dream plate isn’t already taken! Most states, like California, have an online tool where you can check if your combo is up for grabs. Just hop onto your local DMV’s website (like the California DMV Online Services Portal) and see what’s available. It’s quick, easy, and saves you from falling in love with a plate that’s already cruising around town.

Keep It Simple

You want people to get your plate at a glance, not squint and wonder what it means. Keep it short, sweet, and easy to read. Law enforcement needs to be able to spot it quickly too, so avoid anything that looks like a secret code. Think clear and catchy, not confusing.

Get Creative with Abbreviations

This is your chance to shine! Use fun abbreviations that shout “I’m a doc!” or nod to your specialty. Whether it’s “PEDIMD” for pediatricians or “EKGMD” for cardiologists, a little creativity makes your plate memorable and shows off your professional pride. Bonus points if it makes people smile!

Add a Unique Twist If Needed

If your top choice is already taken, don’t sweat it! Toss in a number or symbol to make it yours. Maybe it’s your lucky number, a nod to your graduation year, or something meaningful like your favorite medical code. For example, “DOC2BE” or “RN4LIFE!” Get clever and make it stand out.

Play Nice—Keep It Clean

Most DMVs have strict rules against anything offensive, so keep your plate professional and positive. You want to make people smile or nod in recognition, not cringe. Stick to combos that are fun but respectful—think of it as a reflection of your bedside manner!

Go for Timeless, Not Trendy

Skip the trendy slang or inside jokes that might feel outdated in a few years. Instead, choose something classic that you’ll still love down the road. Think of your plate like a tattoo for your car—you want it to stand the test of time, not leave you regretting it later.

Double-Check for Typos

Before you hit “submit,” take a second to triple-check your combo. You don’t want to be stuck with a plate that says “DOCOTR” instead of “DOCTOR” or “NUR5E” instead of “NURSE.” A quick review can save you from a facepalm moment later!

Seek Inspiration If You’re Stuck

Feeling stuck? No worries! Browse online forums, scroll through social media, or chat with your colleagues for ideas. Sometimes a little brainstorming with friends or seeing what others have done can spark the perfect combo. Inspiration is everywhere—don’t be afraid to look for it.

Sometimes, patients give small gifts to say thank you for the care they receive. Even though gifts are meant to be nice, they can sometimes impact the quality of care if healthcare providers start to favor the patients who give them more gifts. But saying ‘No’ to gifts might hurt the friendship between patients and doctors. Since there aren’t clear rules about getting gifts from patients, providers need to think about both sides.

This article will outline the pros and cons around accepting gifts, examining factors like the patient-provider dynamic, gift value, and timing. You’ll understand the important choices to make for you and your patients while following the right rules. After reading, you’ll feel equipped to establish personal guidelines on gifts that align with your moral compass.

Should Physicians Accept Gifts From Their Patients or Not?

It’s up to you to decide if you want to accept gifts from patients. Your professional boundaries, the connection with the patient, and your clinical judgment should all be taken into account. The factors that should be evaluated are:

➜ Motive:

➜ Value:

➜ Timing:

➜ Professional Guidelines:

➜ Communication:

Case Studies and Real-World Examples / Hypothetical Scenarios

From uncomfortable rejections to touching acceptances, these examples show how leading healthcare professionals maintain boundaries without hurting relationships. See how factors like timing, cultural norms, and institutional rules influence real-life outcomes.

Case 1⃣: A patient offers a $500 gift card

Mr. Jones had surgery and is feeling really thankful. He wants to give you a $500 gift card to show how much he appreciates you. While you appreciate the kind gesture, accepting such an expensive gift would violate your hospital’s policy on gift acceptance from patients. It could also create a perception of favoritism or influence your clinical decisions.

The ethical response ➜ Say a big thank you to Mr. Jones for his kind gift, but let him know that you can’t accept gifts that are too valuable because of the hospital rules. Suggest that a heartfelt thank-you note would mean just as much to you.

Case 2⃣: A Muslim family insists on giving a cultural gift

The Khan family, following a long-standing Islamic tradition, insists on giving you a beautifully crafted tasbeeh (prayer beads) and a small box of dates as a sign of gratitude for the care you provided to their elderly father. While the gift holds sentimental and religious significance, you’re unsure about accepting it due to potential ethical considerations.

The ethical response ➜ It’s nice to accept the gift! Saying no might hurt their feelings because it’s part of their culture and beliefs. But be sure to show that you really like the kind thought behind the gesture, not just the gift itself. This approach keeps a good relationship with the family and upholds professional ethics.

Case 3⃣: A patient brings in some yummy homemade treats.

Mrs. Thompson, who loves to bake, made a yummy pie to say thank you after she got better. The pie looks super yummy, and you can tell it was made with love!

The ethical response ➜ You can happily accept the homemade treats because they are a nice, simple gift from someone who really appreciates you. Just remember to check for any food allergies or special diets, and maybe share the snack with your coworkers!

Case 4⃣: A patient offers tickets to a sporting event

Mr. Williams, who has been your patient for a long time, gives you two tickets to a playoff game because he knows you love the team. Even though the gift is nice, taking it might make other patients think you like Mr. Williams more than others or that it could change how you treat him in the future.

The ethical response ➜ Politely decline the tickets, explaining that while you appreciate the kind gesture, accepting gifts of significant value would be a violation of your professional ethics and hospital policies. Suggest that a heartfelt thank-you note would be just as meaningful to you.

Case 5⃣: A patient gives a gift card before a procedure

Before her procedure, Mrs. Davis gives you a $50 gift card. She says she wants to thank you for the care you will give her.

The ethical response ➜ While the gift card’s value may fall within your hospital’s guidelines, it’s best to decline gifts offered before providing care, as they could be perceived as an attempt to influence your clinical decisions. Thank Mrs. Davis for being so kind, but let her know that you can’t accept gifts until after the procedure because of your professional norms.

Considering Cultural Traditions with Patient Gifts

Even if a gift doesn’t quite align with typical guidelines, it’s important to carefully consider the cultural significance before refusing it. Declining a gift that holds special meaning in a patient’s culture could damage your relationship and come across as insensitive.

If someone from a religious background gives you a gift to say thank you after getting better, saying no nicely might come off as rude and not respecting their customs. Sometimes, it’s okay to accept a really special gift, even if it’s fancier than what you usually take. It can be nice to make an exception for special cases!

You’ll need to use your best judgment when cultural factors are at play. Try to talk openly with the patient. Share your thoughts while being respectful of their traditions. Perhaps you could accept the gift on behalf of your team or department rather than personally. If both sides understand each other, you can usually find a solution that fits for everyone.

The key is to always act with compassion. If the gift refusal would clearly disappoint or insult them, be willing to bend the rules when appropriate. Their cultural perspective deserves consideration.

For example, you may make an exception to accept a $100 gift card from a patient of certain religious background if it’s meant to honor their tradition of giving to providers who aided their healing. Even though you usually say no to pricey gifts, you get that this one is special because of its cultural meaning.

Alternatives to Gift Acceptance from Patients

Instead of accepting gifts from patients, you can also consider these better alternatives that uphold professional ethics:

Redirect gifts to charity. Suggest the patient donate the gift or its value to a cause you both care about. This shows you appreciate the thought while avoiding any conflicts of interest. Charitable donations don’t create any ethical concerns, and they can have a positive impact on the community or a cause that’s important to the patient.

Ask for a review. Nowadays, online reviews are very important and have a big influence on a healthcare provider’s reputation. A nice review from a happy patient can be even better than a gift. It helps bring in new patients and improve the provider’s reputation on the web. Kindly propose they write a positive review about their care experience instead of a gift. Reviews serve as a way for patients to express their appreciation while also helping the provider’s practice grow.

Propose volunteering opportunities. If they have some free time, suggest helping out at a clinic event! Their time is a gift that helps others without any worries about ethical or not.

Propose a get-well card. If they want to give something special, they could make a handmade card to wish them better health. This is a nice way to show you care while still keeping your space.

Suggest celebrating recovery. Suggest that they celebrate getting better or feeling good with their family and friends instead of giving you a gift. This shows you really care about how they feel and stay healthy.

Recommend paying it forward. Tell them to “pay it forward” by doing something nice for another patient instead of giving you a gift. This embodies the spirit of giving without ethical issues.

Express that care is your reward. Tell them that watching them get better makes you really happy as their caregiver. That speaks volumes about your drive to succeed in your career.

Propose a handshake or hug. If a physical gesture is important, offer a handshake, hug, or pat on the back instead of a gift. This creates a human connection without crossing lines.

Sample Responses for Politely Declining Gifts from Patients

When declining gifts from patients, it’s important to first acknowledge their kindness before explaining why you can’t accept. This shows respect and preserves the relationship. Some ways to do this politely:

The key is to first thank them sincerely for the gesture before tactfully explaining you can’t accept due to professional boundaries. This maintains goodwill.

References:

• AMA Code of Medical Ethics, Opinion 8.061: Gifts from Patients
• AMA Code of Medical Ethics, 1.2.8: Gifts from Patient – PDF

As 2025 unfolds, healthcare providers are struggling with a rising wave of claim denials for Durable Medical Equipment (DME). The culprit? Medicare’s opaque frequency limits that dictate DME replacement periods. For providers, this translates to clogged operations and patients left waiting.

But there’s hope on the horizon. Developing expertise in Medicare’s frequency limit nuances is the antidote providers need. With this knowledge, they can comply with requirements, streamline DME delivery, and slash denials.

This blog offers providers a detailed decode of Medicare’s complex frequency rules. Consider it your insider’s guide to seamlessly supplying DME on time, without getting ensnared in Medicare’s red tape. Armed with these insights, providers can meet patient needs promptly and painlessly while keeping denials at bay.

What is meant by Medicare’s “DME Frequency Limits?

Medicare DME frequency limits refer to guidelines determining how often Medicare will cover replacement durable medical equipment (DME) for a beneficiary.

For example, Medicare may allow a new wheelchair every 5 years, a new walker every 3 years, or new diabetic test strips every month. These limits enable Medicare to manage costs and prevent overutilization of equipment.

However, the frequency limits also ensure beneficiaries have access to essential DME on a reasonable replacement schedule. With frequency limits, patients can receive new DME when truly needed, while Medicare can control excessive spending.

Understanding Medicare DME Frequency Limits

➜ Medicare has limits on how often it will cover the replacement of Durable Medical Equipment (DME) such as wheelchairs, walkers, and hospital beds.

➜ These limits are based on the equipment’s Reasonable Useful Lifetime (RUL). The RUL is the expected lifespan of the equipment, calculated from the date it was issued to the beneficiary, not the manufacturing date.

➜ Medicare will typically cover a replacement after the RUL has expired or if the equipment is lost, stolen, or damaged beyond repair.

➜ Your healthcare provider can guide you through the process of obtaining necessary authorizations if your situation warrants an exception to the standard frequency limits.

The following is a table of the specific Medicare frequency limits that have been established for a variety of durable medical equipment (DME). We have grouped the frequency limits based on how long they last. For instance, some items can only be replaced once a month, while others can be replaced only once every few years.

How are the limits for Medicare DME set?

Medicare DME has rules about how often you can get things. These rules help make sure patients get what they need and that costs stay manageable. There are a few things that help decide these limits. Let’s look at each one that helps Medicare figure out the DME frequencies:

Assessing Patient Needs and Equipment Usage

Medicare sets frequency limits for DME by closely analyzing patient needs and equipment usage. This process involves reviewing medical records and claims data to understand how often equipment requires replacement for different conditions. Medicare examines factors like expected equipment life spans, how deterioration occurs with use, and the level of support needed by patients over time.

By gathering data on real-world equipment use, Medicare can establish reasonable limits on replacement frequency. This makes sure patients get the DME they need, without getting too much and wasting it.

Conducting Cost-Effectiveness Analysis

Medicare carefully checks how much things cost to keep the program running with financial stability. These analyses give Medicare a comprehensive understanding of the costs of providing and replacing Durable Medical Equipment (DME) versus the benefits this equipment provides to patients.

The analyses look at factors like how much it costs to buy and take care of equipment over time and how much better it makes people’s health. They also consider if less expensive alternatives could provide similar benefits.

By weighing all these factors, Medicare looks at all these things to make sure it saves money while still helping patients with their health needs.

Engaging with Key Stakeholders

Medicare recognizes the importance of a collaborative approach when setting DME frequency limits. Therefore, Medicare engages with different stakeholders to make sure the rules are easy to follow, make sense for health care, and fit what everyone needs.

To do this, Medicare talks with doctors, medical equipment makers, and patient advocacy groups. Doctors and nurses know a lot about taking care of patients. They understand what is needed for medical equipment to help people feel better. Manufacturers, on the other hand, contribute their expertise on the latest advancements in DME technology, ensuring that the limits are compatible with the available products and innovations.

Crucially, Medicare also seeks input from patient advocacy groups, ensuring that the patient’s perspective is at the forefront of the decision-making process. These groups share important stories about what patients go through. They help create rules that focus on keeping patients happy and healthy.

By encouraging this collaborative atmosphere, Medicare may strike a balance between cost-effectiveness and patient care, ensuring that frequency limits are neither overly strict nor unnecessarily lenient.

Adherence to Regulatory Standards

The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administering the Medicare program, works closely with various regulatory bodies, including the Food and Drug Administration (FDA), to ensure that the DME frequency limits are aligned with the latest medical practices, technological advancements, and safety protocols.

By staying up-to-date with regulatory standards, Medicare can make informed choices when setting or revising the frequency limits for different types of DME. This process looks at scientific facts, clinical studies, and expert advice to figure out how often DME should be replaced or restocked.

Following the rules helps Medicare stay legal and makes sure that the equipment given to people is safe and good quality. Following the rules helps keep everyone safe, makes sure Medicare spends money wisely on the right medical equipment, and leads to better health for the people who need it.

Also, by keeping the DME frequency limits up to date with new rules, Medicare shows it cares about giving people the best and newest medical technology and treatment choices. This active way helps patients on Medicare get the best care and support for their health needs, making them feel better and live happier lives.

Why Medicare DME frequency limits matter?

Medicare Durable Medical Equipment (DME) limits help keep healthcare affordable. Here’s why they matter:

Cost Control

Limits stop waste so Medicare can use funds well. Without them, a patient could get multiple wheelchairs in a short time when not needed. Limits let Medicare spend wisely.

Prevents Budget Overruns

Medicare could run out of money fast if no limits existed. For example, if folks got unlimited replacements of expensive items, Medicare funds would dry up quick. Less would be on hand when truly needed.

Prevents Overuse

Limits prevent folks from overusing medical gear. This way, only needed, required items get provided. It avoids waste. Limits and management keep use of resources proper.

Prevents Excess Requests

With no limits, some may ask for new oxygen machines more than required. This can lead to waste and higher costs. For instance, if a patient asks monthly but only needs yearly. Too many requests can limit resources.

Standardizes Care

Limits give all patients the same care. This makes treatment fair and steady. It highlights the importance of evenly sharing resources.

Prevents Unequal Care

With no standard care, some patients may get more equipment based on their provider. For example, one area may get new walkers yearly while another gets them every 5 years. This can cause unfair differences.

Reduces Fraud

Clear limits make fraud and abuse less likely. Defining necessity helps Medicare spot and stop fraudulent billing easier. Limits and compliance keep the system working properly.

Prevents False Billing

Without fraud oversight, providers could falsely bill Medicare multiple times for the same item. For instance, billing for many oxygen machines with no patient need causes big financial losses.