Orthopedic Billing Challenges and Ways to Tackle Them

Time is money for an orthopedic surgeon. They switch between office consultations and the operating room while striving to run a smooth practice. However, they find it difficult to cope with the unexpected when it comes to orthopedic medical billing as it is more complex when compared to other specialties. Orthopedics often covers a wide range of services and procedures, generating a lot of documentation and thus a lot of coding. So, it comes as no surprise that approximately 35% of orthopedic surgery claims are reported to be incorrectly processed. To add to this, over 25% of the claims get outrightly rejected, out of which 15% have never been resubmitted to the insurance payer. As orthopedic procedures are quite expensive, claim denials could result in a major source of revenue loss for the orthopedic practice. That is why it is important to understand the challenges involved and the ways to tackle them.

Coding issues

Most often, orthopedic specialists deal with a lot of fractures and injuries. With a variety of fracture care codes application of incorrect codes when dealing with fractures and their types could end up in claims denials and revenue loss. The best practice is to conduct on-going, consistent audits. It is also important for orthopedic practice to stay current on the most advanced coding updates to avoid claim denials and revenue loss. They should know the difference between open fractures and closed fractures. If it is not mentioned as either an open or closed fracture, it should be coded as closed. Similarly, if a patient is treated by an emergency room physician for a fracture and attended by an orthopedic surgeon the following day, the first encounter with the emergency room physician will be coded. The 7th character should in no way be influenced by the order of the surgical procedures.

CPT guidelines

Every year the AMA releases a list of additions, revisions and deletions to the CPT code sets. Orthopedic practices must stay up-to-date with the latest version of code sets to avoid denials. When coding for orthopedic procedures it is important to properly understand and translate the documentation into codes, to ensure efficient reimbursements. Orthopedic practices face denials when coders report grafting codes with surgical codes. Hence, care should be exercised when grafting has been done and check if it is an allograft or an autograft, as the codes differ depending on the material the surgeon uses. Hence, coders should stay up-to-date with the coding, rules, conventions and the guidelines when coding physician documentation.

Adapting to ICD 10 changes

The implementation of ICD -10 brought about significant changes to the clinical and administrative workflow of medical practices. Many practices weren’t actually prepared for the change and hence struggled to meet requirements and make profits. The following are some of the changes that every physician needs to pay attention to.

1. When compared to ICD -9, ICD-10 codes are much more detailed about the injury.
2. ICD-9 lacks laterality. ICD-10 codes include laterality and hence physicians need to specify whether the condition occurs on the left, right or is bilateral.
3. ICD-10 codes are more specific than ICD-9 Codes. Hence, physicians have to be more specific and detailed in documenting their patient encounter. This enables coders to apply the right codes and prevent denials.
4. Orthopedic practices need to mention the place where the injury occurred in the body area very specifically and with laterality.
5. ICD-10 guidelines also require you to indicate whether the patient encounter was initial, subsequent or sequel.

Accurate and complete documentation

Accurate and thorough clinical documentation during the patient encounter is crucial to orthopedic medical billing. It has been estimated that a lack of detailed physician documentation can leave about 6% of procedures performed by physicians uncoded. Even if the codes are properly included, it can happen that add-ons and modifiers crucial to maximizing reimbursements and preventing denials may be left out. It is important that the coder has a good grasp of the language and a clear picture of the situation mentioned in the physician documentation. In the same way, physicians can also learn/use the basic coding terms and vocabulary to help coders with accurate coding.

Claim settlement ratio

A study indicates that Medicare reimbursements significantly dropped for orthopedic procedures by an average of 1.5% each year. Errors occur due to lack of knowledge of the complex rules set forth by the different insurance carriers for evaluating a claim. The secret to accuracy is opting to use the latest technology and ensuring that coders stay current with all coding-related updates. Also look for every possible reason that could trigger a denial. Identifying and correcting it before resubmitting to the insurance provider can greatly help to recoup reimbursements.

If you are an orthopedic physician and find it challenging to handle the complexities of orthopedic medical billing, Scribe4Me is here to help you. You can trust Scribe4Me’s orthopedic billing services for accuracy, coding compliance, timely submissions, consistent follow-ups, frequent audits, and much more. We have the right infrastructure, tools, technology and a skilled team of AAPC-certified coders to rev up your reimbursements and keep denials to the minimum. For more information on how Scribe4Me can help overcome billing challenges and keep revenue flowing into your practice reach us at (908)736-4180.