Medical billing and coding tools
Code lookups and form decoders for the day-to-day of medical billing and coding.
More about this page
ICD-10-CM, HCPCS Level II, CPT structural rows, NDC, CARC and RARC, MS-DRG, APC, NUBC revenue and TOB, CMS-1500 and UB-04 field-by-field references.
170 tools in this hub, all free, all in your browser.
Billing & Coding
- Time-Based E/M Code Selector (2021) Map total provider time on the date of an office or outpatient encounter to the corresponding 2021 AMA CPT…
- MDM-Based E/M Code Selector (2021) E&M level by medical decision making.
- NDC 10 ↔ 11 Digit Converter Translate a National Drug Code between its FDA-assigned 10-digit segmentation…
Billing & Reimbursement
- MPFS Allowed Amount (RVU x GPCI x CF) Medicare PFS payment from RVUs.
- Multiple-Procedure Payment Reduction (MPPR) Applies the multiple-procedure payment reduction to a set of surgical or endoscopic lines.
- Bilateral (Modifier 50) Payment by Indicator Bilateral-surgery payment by the MPFS bilateral indicator (0/1/2/3).
- Assistant / Co- / Team-Surgeon Payment Co-surgeon / assistant / team payment.
- Medicare Part B Drug Payment (ASP) What Medicare allows and pays for a Part B drug.
- Medicare 2% Sequestration Adjustment Medicare sequestration.
- NCCI Edit & Modifier-Bypass Checker NCCI Procedure-to-Procedure edit check.
- MUE Units Adjudication (MAI 1/2/3) Medically Unlikely Edit check.
- Modifier 59 vs XE/XS/XP/XU Selector Picks the right distinct-service modifier.
- Global Surgery Period & Required Modifier Surgical global-period check.
- Pricing vs Informational Modifier Order Orders CPT/HCPCS modifiers on the claim line.
- E/M MDM Level by Setting (2023, all places of service) 2023 E&M level by medical decision making.
- Critical Care Time (99291 + 99292 Units) Critical-care time coding.
- Split / Shared Visit & FS Modifier Split/shared visit attribution.
- Prolonged Services (99417 / G2212 Units) Prolonged-services coding.
- Therapy Units (8-Minute Rule vs Rule of Eights) Timed-therapy billable units from cumulative minutes under the Medicare 8-minute rule or the AMA/SPM substantial-portion rule.
- Anesthesia Units (Base + Time + Modifying x CF) Anesthesia payment: (base + time + modifying) units x conversion factor, then the medical-direction…
- HCPCS Drug Billing Units (Dose -> Units) Convert an administered dose to HCPCS/J-code billing units by the code descriptor unit size, with the…
- Drug Wastage (JW / JZ Units, Single-Dose Vial) Single-dose-vial wastage.
- Infusion Hierarchy (Initial Code Picker, 96360-96379) Assign the CPT infusion/injection hierarchy (one initial, then sequential/concurrent/push) across a set of…
- NPI Luhn Check-Digit Validator / Generator NPI Luhn check-digit validation (10 digits) or generation from a 9-digit base, per the CMS/ISO 80840 prefix rule.
- Medicare Beneficiary Identifier (MBI) Format Validator Medicare Beneficiary Identifier (MBI) format validation: the 11-position CMS grammar and excluded-letter rules.
- ICD-10-CM Structural & Specificity Checker ICD-10-CM structural and specificity check: category/subcategory grammar and whether a 7th character is required.
- 835 / EOB Remittance Balancing 835 / EOB remittance balancing: billed minus paid minus the CO/PR/OA/PI adjustments.
- IPPS DRG Payment Estimate IPPS DRG payment estimate: relative weight x the wage-index-adjusted operating+capital base, with the per-diem transfer reduction.
- OPPS APC Payment Estimate OPPS APC payment estimate: relative weight x conversion factor, wage adjusted.
- Medicaid Unit Rebate Amount A drug's Medicaid unit rebate amount.
- Chronic Care Management Codes from Minutes (99490, 99491, 99487) Chronic care management codes from the minutes in a calendar month, by CMS's time thresholds.
Insurance & Patient Literacy
- Medicare Appeal-Level Deadline Calculator Medicare claim-appeal deadline.
- Claim Timely-Filing Deadline Timely-filing deadline: the payer window (Medicare 365 days, or a custom limit) from the date of service and the deadline date.
- Prior-Authorization Decision-Deadline Clock Prior-authorization decision deadline under CMS-0057-F.
- Part D Coverage Decision Clock Part D coverage-decision and exception deadline, in hours from receipt.
- Part D Appeal Ladder The next Part D appeal level and its filing deadline.
- Medicare Advantage Coverage Decision Clock Medicare Advantage coverage-decision deadline.
- Medicare Advantage Appeal Ladder The next Medicare Advantage appeal level and its filing deadline.
- Employer Plan Claim and Appeal Clock (ERISA) Employer health plan claim and appeal deadline under ERISA.
- External Review Clock (Marketplace and Employer Plans) External review filing deadline for group and individual health coverage.
- Medicaid Managed Care Appeal Clock Medicaid managed care appeal deadlines.
- Medicare Fast Appeal Clock (QIO) Medicare fast appeal to the QIO for a hospital discharge or ending services.
- Part B Late Enrollment Penalty Medicare Part B late enrollment penalty.
- Part D Late Enrollment Penalty Medicare Part D late enrollment penalty from the gaps in drug coverage.
- COBRA Deadlines and End Date COBRA notice, election, first-payment and coverage-end dates.
- Part A Premium and Late Increase Medicare Part A premium from quarters of covered work.
- Medicare Enrollment Window and Start Date Which Medicare Part B enrollment window is open on a date, and when coverage starts.
- Marketplace Special Enrollment Window Marketplace special enrollment window and coverage start date.
- Medicaid Work Requirement Check Whether a Medicaid expansion adult meets the monthly work requirement or is excepted.
- What Will I Pay for a Part B Drug? What a patient pays for a Part B drug.
- Federal Poverty Level Percent Income as a percent of the federal poverty guidelines.
- Premium Tax Credit Estimate Estimated Marketplace premium tax credit.
- Employer Coverage Affordability Test Whether an employer's health coverage offer is affordable.
- Amounts Generally Billed (AGB) Percentage A hospital's amounts generally billed percentage.
- Collection Action Timeline (501(r)) When a nonprofit hospital may start extraordinary collection actions.
- Financial Assistance Discount (Sliding Scale) A hospital financial assistance discount from its own sliding scale.
- Good Faith Estimate Deadline When a good faith estimate is due to an uninsured or self-pay patient.
- Patient-Provider Dispute Eligibility Whether a self-pay bill can go to patient-provider dispute resolution.
- Medicaid MAGI Household and Income Each person's Medicaid MAGI household, income and percent of poverty.
- Medicare Part B or Part D for This Drug? Whether Medicare Part B or Part D covers a drug, and why.
- Which Appeal Rules Apply? Which coverage-request and appeal rules apply to a plan and item.
- Check My Hospital Bill Against Its Posted Prices
- Read My Health Insurance Claims File
- Should I Have Paid for This Preventive Care? Whether a private plan may charge cost sharing for a preventive service, citing the federal rule or FAQ that decides it.
- HSA Safe Harbors: What Can Be Covered Before the Deductible? Whether an HSA-qualifying plan can cover an item before the deductible.
- Does My Direct Primary Care Plan Keep HSA Eligibility? Whether a direct primary care arrangement keeps HSA eligibility under IRC 223(c)(1)(E).
- Was This Medicare Advantage Denial Allowed to Use These Criteria? Whether a Medicare Advantage denial followed the process rules: whose criteria, public evidence, reviewer, 90-day transition.
- Part D Redetermination Request Letter Builds a Part D redetermination request with its deadline.
- ERISA Appeal Letter (Employer Coverage) Builds an employer-plan appeal that asserts the claimant's ERISA review rights.
- Medicare Advantage Reconsideration Request Letter Builds a Medicare Advantage reconsideration request with its deadline.
- External Review Request Letter Builds an external review request with its four-month deadline.
- Medicaid Appeal or Fair Hearing Request Letter Builds a Medicaid managed care appeal or fair hearing request with its deadline.
- Part D Exception Request Letter Builds a Part D exception request with the prescriber statement the rule requires.
- Letter of Medical Necessity (Drug) Builds a letter of medical necessity for a drug.
- Extra Help and Medicare Savings Program Screen Screens for Extra Help and the Medicare Savings Programs.
- 60-Day Overpayment Report-and-Return Clock Medicare 60-day overpayment report-and-return deadline from the identification date (42 CFR 401.305).
- Medicare Patient Cost-Share (Part A / B / SNF) Medicare patient cost-share.
- Coordination of Benefits & Medicare Secondary Payer Coordination of benefits.
- Contractual Write-Off vs Patient Balance Allowed-amount split: contractual write-off, patient responsibility (deductible + coinsurance + copay), and…
- No Surprises Act Cost-Share (QPA-Based) No Surprises Act cost-share.
Workflow & Documentation
- Home Health Certification and OASIS Clock Home health certification and assessment dates.
- DME Capped Rental and Oxygen Clock When a Medicare DME rental ends.
- Inpatient Rehabilitation Timing Check Whether an IRF stay meets its timing rules.
- Inpatient-to-Observation Appeal Rights (MCSN) Whether a patient changed from inpatient to observation can appeal.
- Hospice Aggregate Cap A hospice's aggregate cap for the year.
- Important Message from Medicare Timing When the Important Message from Medicare is due.
- Prior Authorization Checklist Generator Generate a printable prior-authorization checklist that lines up the data fields most payers request before…
- Observation Notice (MOON) Deadline When the Medicare observation notice is due.
- NOMNC Delivery Deadline Notice of Medicare Non-Coverage deadline, 2 days before services end.
- SNF Qualifying Stay and Benefit Days Skilled nursing qualifying stay.
- Hospice Benefit Period Clock Hospice benefit periods of 90, 90, then 60 days, with certification and face-to-face windows (42 CFR 418.21, 418.22).
- HIPAA Breach 60-Day Notification Clock Compute the three statutory deadlines a covered entity faces under the HIPAA Breach Notification Rule…
Revenue Cycle & Utilization
- Appeal Worklist by Deadline A worklist of denied claims sorted by appeal deadline, then dollars.
- X12 835 Remittance Reader Read an X12 835 remittance file and prove its arithmetic before posting.
- X12 837 Claim File Check Check an X12 837 professional or institutional claim file before submission.
- X12 271 Eligibility Response Reader Read an X12 271 eligibility response without sending it anywhere.
- X12 277 Claim Status Reader Read X12 277 claim-status responses and 277CA claim acknowledgments without uploading them.
- X12 999 Acknowledgment Reader Read X12 999 implementation acknowledgments without uploading them.
- X12 278 Prior Authorization Response Reader Read X12 278 prior authorization responses without uploading them.
- Compare One Service Across Hospital Price Files
- Hospital Price Transparency File Check Check a CMS Hospital Price Transparency v3.0.0 machine-readable file in your browser.
- Prior Authorization FHIR Bundle Check (Da Vinci)
- Insurer Price File (Transparency in Coverage) Check
- Claims Paid as a Percent of Medicare What a health plan paid as a percent of Medicare.
- Find Negotiated Rates in an Insurer Price File
- Denial Pattern Report Turn a month or quarter of X12 835 remittances into a denial and adjustment report.
- Paid Below Contract Check Compare the allowed amount on each 835 service line with the contract rate you supply.
- Denial Next Step and Deadline What to do next about a claim denial, and by when.
- Prior-Auth Packet Linter A deterministic prior-authorization packet linter that runs entirely in your browser.
Medication Access & Pharmacy
- Does Original Medicare Require Prior Authorization? Whether Original Medicare requires prior authorization for a code.
- Authorization Run-Out and Renewal Date When an authorization runs out, by its end date or by its units, and the date to submit the renewal.
- Authorization Units to Request Billing units to request for an authorization period.
- Quantity Limit Check Whether a prescription fits a plan quantity limit.
- Medicare IRMAA Medicare IRMAA: the monthly Part B and Part D amounts added for income above the published brackets, by filing status.
- Part D Drug Cost Through the Year What a Part D drug costs through the year.
- Medicare Prescription Payment Plan Bill The Medicare Prescription Payment Plan bills month by month.
- Copay Card Run-Out and Accumulator Impact When a copay card runs out and the first bill arrives.
- Medicare Negotiated Drug Price Check Whether a drug has a Medicare negotiated price on a date.
- Dose Rounding to Whole Vials Rounds an ordered dose to whole vials within a policy threshold.
- Infusion Chair Day Planner An infusion center's chair day, scheduled first-fit.
- Can This Product Be Substituted? (Orange Book and Purple Book)
- Adherence: PDC, MPR and Gap Days Proportion of days covered, medication possession ratio and gaps from one drug's fills.
- Medication Synchronization Short Fills A medication synchronization plan.
- Part D Adherence (PDC, Star Method) Part D adherence rates by the Star Ratings method from a fill history.
- Adherence Outreach List (Who Can Still Reach 80%) Which patients can still reach 80% adherence this year, and how much slack each has.
- Step Therapy History Check Whether a patient's drug history meets a plan's step therapy.
- Payer Criteria Checklist Checks marked prior authorization criteria against the policy's own logic.
- Payer Prior Authorization Report Check Checks a payer's posted CMS-0057-F prior authorization report.
- What Changed in This Payer Policy? What changed between two versions of a payer's published criteria, criterion by criterion, with stricter thresholds first.
- 340B Hospital Eligibility Whether a hospital meets the 340B statutory tests, and which restrictions apply.
- 340B Orphan Drug Exclusion Whether an orphan-designated drug is excluded from 340B pricing for an entity.
- 340B Patient Definition Check Whether a person is a 340B patient for a prescription.
- 340B Prescription-to-Encounter Match Match each prescription to an eligible encounter under a covered entity's own look-back, registered-site and referral policies.
- 340B Duplicate Discount and Claim Identifiers What a 340B claim must carry and whether 340B stock may be used, by payer.
- 340B Ceiling Price and Unit Rebate Amount A drug's 340B ceiling price and Medicaid unit rebate amount.
- Negotiated-Price Refund Check (Pharmacy) The refund a pharmacy should get for a Medicare negotiated-price drug, and by when.
- Negotiated-Price Refund Reconciliation (Pharmacy, 835 Files)
- PBM Reimbursement Check Whether a pharmacy claim was paid what the PBM contract says.
- Pharmacy Margin Against NADAC A pharmacy claim's margin against NADAC or the pharmacy's invoice cost.
- Pharmacy Spread Check: Claims Against NADAC A health plan's pharmacy claims against NADAC.
- Does This Diagnosis Support This Code Under the LCD? Whether a diagnosis supports a HCPCS or CPT code under the Medicare billing and coding articles for a state.
- Benefits Investigation Cost Summary What a patient will pay for a therapy under the plan found in a benefits check.
- Cost by Site of Care What a therapy costs the plan and the patient at each site of care.
- Annual Therapy Cost Comparison Compares the yearly cost of up to three regimens.
- Budget Impact Per Member Per Month Spreads a budget impact across a health plan's members and months.
- Controlled-Substance Refills Left Controlled-substance refills left under federal rules.
- C-II Partial Fill and Emergency Deadlines C-II partial-fill and emergency prescription deadlines.
- Multiple C-II Prescriptions Check Checks a series of C-II prescriptions against the 90-day total and the earliest-fill-date rule (21 CFR 1306.12(b)).
- Days Supply Calculator Days supply for tablets, liquids, insulin pens, inhalers and eye drops.
- Earliest Refill Date Earliest refill date from the last fill, its days supply and the plan threshold.
- Part D Cost Sharing for a Short Fill (Daily Cost-Sharing Rate) Part D cost sharing for a fill shorter than the month's supply.
- Medicare Part B Supplying and Dispensing Fees (42 CFR 414.1001) Medicare Part B supplying and dispensing fees for a pharmacy.
- DMEPOS Refill Contact and Delivery Window (Medicare) The Medicare window for refilling DMEPOS supplies.
- Long-Term Care 14-Day Dispensing Check (Part D Short Cycle) The Part D 14-day dispensing rule in long-term care.
- Part D Prompt Payment Due Date and Interest (Pharmacy Claims) When a Part D plan must pay a retail network pharmacy's clean claim.
- Part D Insulin Cost-Sharing Cap (Lesser of $35 or 25%) The Part D cost-sharing cap on a covered insulin fill, plan year 2026 and later.
- Cost of Dispensing per Prescription and Break-Even Volume A pharmacy's cost of dispensing per prescription, from its own costs.
- Medicaid Federal Upper Limit (FUL) Check The Medicaid federal upper limit for a multiple source drug.
- Medicaid Fee-for-Service Drug Payment (Lowest-Of) Medicaid fee-for-service payment for a drug as the lowest of several amounts.
- Part D Transition Supply: Is One Owed, and How Much? Whether a Part D plan owes a temporary transition supply, and how many days.
- Effective Rate and Net Margin Reconciliation (AWP Discount Guarantee) A pharmacy's achieved effective rate against a contract guarantee, for brand or generic claims over a period.
- Part D MTM Targeting Criteria Check (Diseases, Drugs and Cost Threshold) Whether a member meets the Part D medication therapy management targeting criteria.
- Part D Drug Management Program Criteria Check (OMS) Whether a member meets the Part D drug management program criteria.
- Part D Opioid Safety Edits: Which One Fires? (90 MME, 7-Day, 200 MME) Which Part D opioid point-of-sale safety edit would fire, and the way past it.
- Part D Drug Management Program Notice and Limitation Dates Part D drug management program notice dates from the initial notice.
- Medicare Glucose Test Strip and Lancet Quantity Check (LCD L33822) Medicare home glucose test strips and lancets against LCD L33822.
- Statin Use in Persons with Diabetes (SUPD, Star Method) Statin Use in Persons with Diabetes by CMS's Star Ratings method (2027 Technical Notes, measure D11).
- Concurrent-Use Safety Measures (COB, Poly-ACH, Poly-CNS) The Part D concurrent-use safety measures by CMS's published method.
- Opioid Display Measures (High Dosage, Multiple Providers, Initial Long Duration) The Part D opioid display measures by CMS's published method.
- MTM Review Due Dates and CMR Completion Rate Part D MTM review dates and the CMR completion rate from a list of enrollees.