Orthopedic Billing - All you Wanted to Know!

Did you know that 35% of the claims made in Orthopedic surgery are incorrect, and 25% of them get rejected? If you ask an orthopedic medical professional, they will tell you that orthopedic coding and billing are tedious and, in medical schools, they aren’t taught very well. However, when practice starts in real life, it is essential to get knowledge for getting paid for the services provided while dealing with the following complexities.

Orthopedic Billing Complexities

The new ICD-10 has revised 134 codes, deleted 143, and added 264 new codes in orthopedic coding. Furthermore, the introduction of modifiers like XU, XE, XP, and XS is quite pathbreaking in the field, accompanied by the new rules for modifier 59. All these recent changes and the existing coding and billing practices in Orthopedic make the process quite complex.

As a result, the Orthopedic biller and coder need to document the treatment carefully and ensure proper codes are used and charges are placed for the services properly. It is also possible to over-code or under-code in Orthopedic treatment because there are several instances where one service overlaps with the other.

Hence any error in the incomplete demographic entry of the patient or the lack of prior verification that does not approve the eligibility would mean a rejection claim. Also, any authorization errors, failing to know the preferences of the insurer, and meeting the deadline with wrong coding for the treatment would stop the revenue collection.

Begin with Using the Correct Modifiers

The two-character designators used in Orthopedic billing denote how the procedural codes and services are to be applied for the services so the reimbursement can be claimed. When these modifiers are used accurately, they can provide an accurate and detailed medical record of the transaction. In orthopedics, there are two levels of modifiers, Level I and Level II. The Orthopedic billers and coders must have an in-depth knowledge of the modifiers and the codes that are suitable and permissible for a service provided. Any misuse of the modifiers and codes can lead to claim rejection, denial, fines, and in rare cases, even investigation of the practice.

What Else? Top 5 Billing Guidelines for Orthopedic Practice

Given the complex nature of Orthopedic coding and billing, five simple guidelines can be followed to ensure no revenue loss from the billing. These guidelines can minimize claim denials and enhance your revenue management system as follows:

1. Insurance coverage verification

From the beginning, the best way to keep the Orthopedic practice efficient is by taking the time to understand the patient’s insurance policies and verify the aspects of it. It must include pre-authorization, verifying the coverage given by the insurance company, and the type of orthopedic medical services it covers. This will help the practice to understand the reports sent by the insurance company and how to interpret them while ensuring whether the insurance covers the service your facility will render. Verification of the insurance coverage can warrant that your orthopedic billing is in the correct order while saving money and time, thus preventing any claim rejections or denials later.

2. Checking patient information

The importance of this point can never be emphasized enough, that is, checking the patient’s details, like the spelling of their name, date of birth, and other information that are easy to overlook. A simple mistake in the patient’s demographic would mean the practice is heading toward claim rejection or denial. The best way to ensure that everything is correct in the patient’s form is by making the admin staff go over the form filled by the patient and check that they are consistent with the insurance policy for the claim.

3. On-Time Claim 

A standard procedure, process, and metrics for submitting the claim in a given time frame must be used to ensure no claim delays. As a practice, you must be aware of the claim deadlines, and the insurance companies provide a time limit to submit the claims. When you meet the deadline, the chances of claim denials are less, and even if a claim is denied, you have the time to re-check and resubmit, decreasing the chances of revenue loss.

4. Correct coding

Payers can sometimes deny claims because the codes need to be more specific. The insurance companies not only require as much information as you can provide them about the service but also justify that the codes used are correct for the procedures. It is vital that orthopedic coding and billing are compliant with the new ICD-10 coding regulations and standards.

5. Finding the right partner

Keeping up with the changing rules and regulations, orthopedic coding practices, and other insurance companies’ updates can be daunting. Training the in-house staff with these changes means spending more time and money on these while removing the concentration from offering better services to the patient. One of the best ways to ensure the on-track revenue cycle with accurate orthopedic billing and coding is by partnering with an expert like 24/7 Medical Billing Services. They specialize in orthopedic billing and coding, enhancing your experience in boosting the practice revenue.

Read more: Top CPT Codes and Modifiers for Orthopaedics Billing Services