Pulmonology practices manage a revenue cycle that is more complex than many general physician practices. Diagnostic testing, procedural services, chronic respiratory conditions, prior authorization requirements, and payer-specific documentation rules can all affect how quickly a practice gets paid.
The challenge is rarely limited to submitting a claim. Revenue can be lost at several points, from eligibility verification and charge capture to coding, claim submission, payment posting, and accounts receivable follow-up.
Here are six common RCM challenges that pulmonology practices face, as well as how to address them.
1. Inaccurate or Incomplete Charge Capture
Charge capture is one of the first points where revenue leakage can occur. Pulmonologists may provide multiple services during a single encounter, particularly when office visits are combined with diagnostic testing or procedures. If a service is not captured correctly, the practice may never have the opportunity to bill for it.
Common problems include missing charges, incorrect units, incomplete procedure documentation, and discrepancies between clinical records and submitted charges. Practices using specialized pulmonology medical billing services can establish structured charge-review workflows that connect provider documentation with the services reported on each claim.
How to Address It
Practices should establish a consistent process for reconciling provider documentation with charges before claims are submitted. Billing teams should also understand the procedures performed by pulmonologists and know which documentation elements support each billable service.
Regular charge audits can identify recurring gaps and help practices determine if problems originate with documentation, coding, or the charge-entry process.
2. Pulmonary Coding Errors
Pulmonology includes a wide range of diagnostic and procedural services, which makes coding accuracy particularly important. Small differences in documentation can affect the diagnosis or procedure code selected for a claim.
For example, pulmonary practices may bill for pulmonary function testing, bronchoscopy, critical care, thoracentesis, sleep-related services, and other procedures with specific coding and documentation requirements.
Using an unspecified diagnosis when the medical record supports greater specificity can also create medical necessity problems.
How to Address It
Coding teams should review the clinical documentation before assigning codes rather than relying on recurring codes or previous claims. Practices should also monitor payer policies and coding updates that affect commonly billed pulmonary services.
A pre-submission coding review can identify mismatches between diagnoses, procedures, modifiers, units, and documentation before the claim reaches the payer.
3. Prior Authorization Delays
Prior authorization can become a significant source of administrative work for pulmonary practices. Certain medications, diagnostic services, equipment, and advanced procedures may require approval before treatment or testing is provided.
When authorization is missing, expired, or submitted with incomplete information, the resulting claim may be delayed or denied.
How to Address It
Authorization workflows should begin before the scheduled service whenever possible. Staff should verify the patient’s current coverage, determine whether authorization is required, submit the necessary clinical information, and document the authorization number and approved services.
Maintaining a centralized authorization workflow also makes it easier to identify pending requests before they affect scheduled appointments or claims.
4. Claim Denials and Rework
Denials are another major challenge for pulmonary practices. A denied claim requires additional staff time and can delay reimbursement significantly.
Common causes include coding errors, missing modifiers, medical necessity issues, authorization problems, incorrect patient information, and payer-specific claim requirements.
The cost of a denial is therefore greater than the value of the unpaid claim. Staff must research the reason, correct the underlying issue, resubmit or appeal the claim, and continue tracking it until payment is received.
How to Address It
The strongest denial strategy is prevention rather than simply increasing the number of appeals. Practices should analyze denial patterns by payer, procedure, diagnosis, and reason code to identify recurring problems.
For example, if a particular payer repeatedly denies pulmonary function tests because of diagnosis selection, the practice can address the coding or documentation issue before additional claims are submitted.
A denial dashboard can also help management distinguish isolated errors from systemic problems that require workflow changes.
5. Slow Accounts Receivable Follow-Up
A claim that has been submitted successfully is not necessarily a claim that will be paid on time. Unpaid claims can remain in accounts receivable when follow-up is inconsistent, or billing teams lack clear priorities.
This is particularly problematic when practices have large numbers of aging claims across multiple payers.
How to Address It
A/R follow-up should be organized according to claim age, balance, payer, and denial status. High-value and older accounts should receive appropriate priority rather than relying on a first-in, first-out approach.
Practices should also track aging trends regularly. An increase in claims over 90 or 120 days can indicate problems with payer follow-up, claim submission, authorization, or payment posting.
6. Difficulty Keeping Up With Payer and Coding Changes
Billing requirements do not remain static. Medicare and commercial payers regularly update coding policies, reimbursement rules, coverage requirements, and claim submission guidelines.
For a pulmonary practice, keeping track of these changes can be particularly demanding because billing teams must understand both general healthcare billing rules and the specific procedures and diagnoses used in pulmonology.
How to Address It
Practices should establish a process for reviewing relevant payer updates and translating them into billing workflows. Coding teams should receive regular training, while charge masters, claim edits, and internal billing guidelines should be updated when requirements change.
Working with specialized pulmonology billing companies can also give practices access to teams that routinely monitor specialty-specific billing requirements and reimbursement workflows.
Final Thoughts
Pulmonology practices face a combination of clinical, coding, payer, and administrative requirements that can make revenue cycle management challenging. Charge capture errors, coding problems, authorization delays, denials, slow A/R follow-up, payment discrepancies, and limited financial reporting can all affect the practice’s ability to collect what it has earned.
By regularly reviewing each stage of the revenue cycle and addressing recurring sources of revenue leakage, pulmonary practices can create a more consistent billing operation while allowing clinical teams to remain focused on patient care.
