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Orthopedic billing is notably complex process that requires a deep understanding of medical coding, insurance regulations, and compliance requirements. With the ever-changing landscape of healthcare, staying up-to-date with the latest billing practices and industry trends is crucial. Failure to comply with billing and coding regulations can result in the submission of inaccurate claims and subsequent financial losses. Partnering with an orthopedics medical coding company can help physicians diligently adhere to specific guidelines to ensure accurate coding, streamline the billing process, maximize revenue, and reduce claim denials. With a thorough understanding of orthopedic billing and coding aspects, experts can manage the claim submission process efficiently, resulting in optimal reimbursement. Let’s dive into the main challenges of orthopedic billing and key strategies to successfully navigate the process.

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Unique Challenges of Orthopedic Billing

Orthopedic billing presents distinctive hurdles that necessitate specialized knowledge and expertise. One of the primary challenges involves accurately coding orthopedic procedures. The intricate nature of orthopedic surgeries and treatments often demands the utilization of specific codes that precisely capture the essence of the procedure. For example, shoulder surgery coding includes numerous CPT codes related to amputation, arthrodesis, arthroscopy, excision, fracture and/or dislocation, incision, intro or removal, manipulation, and repair/revision/reconstruction. Furthermore, surgical cases are often complex, and multiple procedures may be required to resolve a patient’s ailments. Failure to code accurately can result in claim denials or inadequate payments.

Orthopedic surgeons also experienced a significant expansion in their code selection with the implementation of ICD-10, surpassing that of any other medical specialty. This can be attributed to the comprehensive coverage of body regions within orthopedic ICD-10 codes, resulting in a substantial number of codes generated to date.

Another hurdle involves navigating the complexities of insurance companies and their continually evolving policies and requirements. Insurance companies may have varying reimbursement guidelines, which can be confusing. Additionally, these companies may request additional documentation or impose stringent deadlines for claim submission, further adding to the administrative burden. In addition to the nuances of coding for orthopedic procedures, orthopedic billing guidelines are often subject to changes, making it difficult for to stay up to date.

Best Practices for Orthopedic Billing

    • Verify patient coverage: Insurance eligibility verification is the initial and crucial step in a well-functioning medical billing cycle. Ensuring insurance coverage verification is a crucial aspect of maintaining the efficiency of the orthopedic billing process. By proactively verifying coverage and obtaining pre-authorization from the patient’s insurance carrier, practices can prevent potential denials and coverage issues that may arise later on.

It is essential for orthopedic practices to thoroughly assess patient information and verify the active coverage provided by each patient’s insurance carrier, specifically for the type of medical services they will be providing. Additionally, it is important for practices to understand the documents sent by their insurance company in order to effectively interpret whether their policy encompasses the specific medical care they are providing. By understanding this, they can make informed decisions regarding billing and ensure proper reimbursement for the services rendered.

  • Ensure accurate ICD-10 and CPT coding: Orthopedic billing codes play a vital role in the billing process as they accurately represent the specific orthopedic procedures, diagnoses, and services delivered to patients. Precise coding is essential to ensure proper reimbursement and minimize the risk of claim denials.

Proficiency in the diverse code sets employed in orthopedic billing, such as the current CPT codes and ICD codes, is crucial. Common CPT codes for orthopedics include:

Evaluation and Management: 99201 – 99499
Anesthesia: 00100 – 01999; 99100 – 99140
Surgery: 10021 – 69990
Radiology: 70010 – 79999
Pathology and Laboratory: 80047 – 89398
Medicine: 90281 – 99199; 99500 – 99607
The common orthopedic ICD-10 codes include:
Cervicalgia: M54.2
Osteoarthritis: M17.0 – M17.2
Pain in shoulder: M25.511 – M25.519
Pain in limb: M79.601 – M79.676
Pain in hip: M25.551 – M25.559
Pain in ankle and foot: M25.571 – M25.579

Intervertebral disc disorders and Radiculopathy: M51.14 – M54.17

Being well-versed in these code sets is essential for accurate documentation of services and diagnoses, thereby facilitating appropriate reimbursement for the services rendered. Moreover, some specialties cross multiple CPT code categories – for example, hand surgery incorporates techniques from orthopedics, plastic surgery, general surgery, neurosurgery, etc.

  • Proper use of modifiers: Orthopedic billing modifiers play a crucial role in conveying supplementary details about the services and procedures delivered to a patient. These modifiers are attached to medical billing codes to facilitate accurate processing of claims and ensure proper reimbursement for healthcare providers. Selecting the appropriate modifier based on the service provided is crucial for successful billing. Accurate documentation of the type of service provided, the duration of the service, and any other relevant information can help correct use of billing modifiers. As payers may have different guidelines on modifier use may differ, it is also important to check the payer’s rules before appending a modifier. Neglecting to take modifiers into account or employing them incorrectly can result in claim denials. The frequently used orthopedic billing modifiers are: modifier -51, modifier -59, modifier -LT and -RT, modifier -78, and modifier -22.
  • Improve documentation: Effectively documenting clinical and surgical encounters is vital to ensure successful claim submission and reimbursements. Orthopedists should clearly document procedures performed, including specific details such as any encountered complications and the medical necessity of the treatment. Comprehensible operative report and procedure notes are essential for coders to accurately translate the procedures performed into billable CPT codes. Additionally, capturing the patient’s comprehensive medical history, including pre-existing conditions, is essential for accurate coding and billing. Inadequate or ambiguous documentation can result in significant revenue loss. Thorough documentation ensures that all provided services are accurately recorded and supported by the appropriate evidence, mitigating the risk of claim denials and audits, and optimizing revenue.
    • Understand and follow bundling rules: Bundling refers to the process of grouping together related healthcare services and procedures into a unified billing code. In orthopedics, certain services should be bundled and billed as a single entity, while others may require unbundling and individual billing.

Unbundling takes place when a procedure’s component parts are billed using multiple CPT codes, despite the existence of a single code that encompasses the entire procedure. Denials are frequently attributed to the unbundling of services. Common unbundling errors involve shoulder and knee procedure coding. An AAPC article explains: “Both the Centers for Medicare & Medicaid Services (CMS) and the AAOS recognize three compartments of the knee: medial, lateral, and suprapatellar. It’s inappropriate to append modifier 59 Distinct procedural service to unbundle surgical procedures performed in the same compartment(s)”.

Ensure timely claim submission: It is crucial to submit claims in a timely manner. Establishing a standardized process can help ensure that claims are promptly filed. It is also important to stay well-informed about the specific deadlines and limitations set by each insurance carrier. To avoid common mistakes that lead to claim denials, familiarize yourself and your staff with the common reasons for denials. Implementing regular reporting (daily, weekly, monthly) and conducting timely audits can help efficiently track pending claims.

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With all the challenges involved in orthopedic billing, outsourcing the task is a valuable option to consider. Outsourcing allows practices access to billing professionals well-versed in orthopedic billing regulations, coding, and insurance requirements. With their expertise in providing in orthopedic medical billing services, they can ensure accurate coding and billing, contributing to improved revenue cycle management. By offloading the administrative burden of billing, practices can eliminate the overhead costs associated with in-house billing, save their staff’s time and focus on patient care.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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