Billing & Coding

The Challenge of Secondary Insurance A patient finds a lactation practice advertised as “in network with Cigna through Wildflower.” She has Cigna coverage and expects to use that benefit. However, she soon discloses that Cigna is her secondary insurance. Unfortunately, Wildflower will not allow the patient to be entered into its system when Cigna is not the primary payer. The actual practice does not have a direct Cigna contract. If the practice bills Cigna independently, its

Changing billing support is an operational handoff. Before choosing a start date, decide who will handle each claim, how records will be transferred, and how your practice will check that nothing is missed. This checklist is designed for independent healthcare practices, including IBCLCs, pediatric, maternal health, nutrition, and therapy providers. 1. Review your current agreement and access Check your current service agreement for notice requirements, outstanding fees, reco

Midwifery office testing can require CLIA certification. Distinguish specimen collection from testing and verify the test, site, and billing requirements.

California Medi-Cal postpartum doula coverage can begin after pregnancy. Review initial visits, additional recommendations, and the patient's benefit.

Review pediatric Medicaid denials through EPSDT when applicable. Identify the denial reason, clinical support, and state or managed care appeal process.

Private-pay therapy practices need usable good faith estimates. Review recurring services, expected charges, and changes to the treatment arrangement.

Psychotherapy coding follows actual treatment time. Review counseling appointment defaults, documentation, and shortened sessions before billing.

Before accepting cash for Medicare-covered NP care, review opt-out eligibility, affidavits, private contracts, effective dates, and renewal obligations.

Perinatal mental health screening needs a reviewer and documented action. Keep questionnaire scores, clinical assessment, and billing requirements clear.

Medicare's initial therapy certification exception needs a qualifying referral and proof the plan was sent within 30 days. Build a reliable PT workflow.

OT home visits and telehealth from home use different place-of-service definitions. Align appointment types, encounter notes, and payer instructions.

Medicare medical nutrition therapy and diabetes self-management training cannot share a service date. Coordinate appointments before the patient arrives.

Check breast pump coverage, supplier requirements, authorization, and accessories before a lactation practice promises insurance reimbursement.

Learn what Medicare requires in a speech-generating device evaluation and how SLP practices can coordinate the evaluation, order, and equipment request.

October 2026 | Sunshyn Credentialing & Medical Billing Healthcare providers are being asked to deliver more comprehensive, coordinated, patient-centered care. At the same time, reimbursement policies are increasingly raising a troubling question: How much clinical work can an insurance company classify as overlapping before it stops paying for that work separately? Recent developments involving modifier 25, maternity billing, and lactation reimbursement illustrate why this qu

Clinical collaboration and claim reporting answer different questions An NP practice has a collaborating physician. Someone then suggests submitting every visit under the physician because the physician already participates with the payer. Before that becomes the billing workflow, ask which rule actually permits it. A collaboration agreement can address clinical or state-law requirements without establishing the claim arrangement for every service the NP provides. Medicare’s

Several people can participate in one patient’s treatment A family attends a therapy session together. The practice now needs to explain whose treatment the encounter represents, how the others participated, and which service was provided. That question matters clinically before it matters financially. Participation in a session does not automatically make every person an independently treated patient with a separately billable service. A Medicare contractor’s psychiatry and

A referral does not settle every coverage question A patient arrives with a referral that says nutrition counseling. The dietitian can assess the patient’s needs, but the referral alone may not establish eligibility under the benefit the practice plans to bill. Original Medicare’s medical nutrition therapy benefit illustrates the distinction. Medicare.gov lists eligibility involving diabetes, kidney disease, or a kidney transplant within the preceding 36 months, along with a

The code determines how units work A feeding treatment lasts an hour instead of half an hour. The clinician provided more care, but the billing team cannot assume the claim should contain twice as many units. The first question is whether the reported service uses a timed or untimed code. ASHA identifies 92526, used for swallowing and oral function treatment for feeding, as an untimed service reported once per date of service regardless of the total treatment time. Applying a

For OB/GYN practices, the upcoming maternity coding changes reach far beyond updating numbers in a billing system. They affect how care is documented, when claims are submitted, how reimbursement is negotiated, and what patients are told about their financial responsibility. Beginning January 1, 2027, the CPT maternity care structure replaces traditional global obstetric codes with separate reporting for prenatal care, labor management, delivery, and postpartum care. The upda