Everything You Need To Know About Orthopedic Medical Billing
Everything You Need To Know About Orthopedic Medical Billing

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If you want to know more about orthopedic medical billing or want to outsource your billing process, this is the article for you. This short blog discusses everything you need to know, including what orthopedics is, why orthopedic medical billing is complex, common mistakes made during the process, and more.

What Is Orthopedics?

Orthopedics is a medical specialty focused on diagnosing, treating, and preventing disorders and injuries related to the musculoskeletal system, including bones, joints, ligaments, tendons, and muscles. Orthopedic doctors, also known as orthopedists, are trained to address various musculoskeletal issues, from fractures and sports injuries to degenerative diseases like arthritis.

In orthopedics, physicians use non-surgical approaches such as physical therapy, medication, and exercise to alleviate pain, improve function, and promote healing. Additionally, orthopedic surgeons are skilled in performing surgical procedures when necessary, such as joint replacements, spine surgeries, and repairing fractures. Orthopedic surgeons usually collaborate with other healthcare professionals like physical therapists, occupational therapists, and pain management specialists to provide comprehensive and tailored treatment plans.

What is Orthopedic Medical Billing

What Is Orthopedic Medical Billing?

Orthopedic medical billing involves documenting, verifying, and processing payments for services provided at an orthopedic medical billing facility. This involves:

  • Verification of patient’s insurance eligibility: This process typically involves contacting the insurance company to check the patient’s policy status, coverage, and any associated co-pays or deductibles. Verifying insurance eligibility helps ensure that orthopedic practices bill accurately and avoid complications during the reimbursement process.
  • Entry of patient demographics: Accurate entry involves capturing essential client information, such as name, address, phone number, date of birth, and insurance details.
  • Documentation and coding of services and procedures performed: This involves meticulously documenting all services and procedures performed during the patient’s visit to an orthopedic facility. Orthopedic medical coders then use specific codes to represent each service or procedure provided, ensuring that the billing reflects the complexity and specificity of the care delivered.
  • Timely claims submission: By submitting claims on time, orthopedic practices can expedite the reimbursement process and ensure they receive payment for the services provided without unnecessary delays.
  • Reprocessing denied claims: When a claim is denied, orthopedic billing experts gather additional information, correct coding errors, or provide the necessary documentation to support the claim. This proactive approach helps ensure that rightful payment is obtained for the services provided and contributes to a more efficient revenue cycle.

Why Orthopedic Medical Billing Is Complex

Orthopedic medical billing poses challenges due to three main factors.

  1. Firstly, a considerable percentage of errors arise in orthopedic surgery claims, with around 35% of claims being incorrect and 25% facing rejection. These high error and rejection rates contribute to the overall complexity of the billing process. Due to the nature of orthopedic treatments, there is a potential for both over-coding and under-coding, as different services may overlap or have interrelated aspects that need to be appropriately accounted for in the billing process.
  2. Secondly, orthopedic professionals often encounter difficulties due to the limited education and training they receive in orthopedic coding and billing during their medical school years. The lack of comprehensive instruction in this area further adds to the complexities faced by orthopedic professionals when handling billing procedures.
  3. Another key complexity in orthopedic medical billing is the frequent updates and revisions in coding. With the introduction of the new ICD-10, orthopedic coding has undergone substantial changes, including the revision, deletion, and addition of numerous codes. Moreover, implementing modifiers, along with new rules for existing modifiers, has further increased the intricacy of the process.

Common Mistakes Made During Orthopedic Medical Billing

  • Failure to Verify Insurance: In a busy orthopedic practice, administrative staff may overlook the importance of verifying patient coverage. They may prioritize other tasks or assume that insurance information provided by patients during registration is accurate. This oversight can result in claims being submitted without proper verification, leading to potential denials or delays in reimbursement.
  • Incorrect Entry of Demographics: Even the smallest mistake, such as an inaccurate date of birth or a spelling error, can result in an automatic denial from insurance companies. Therefore, meticulous attention to detail is necessary to ensure that each piece of patient demographic information is recorded correctly to prevent potential billing issues and denials.
  • Incorrect Documentation: Orthopedic medical billing operates within a nuanced system of codes and regulations. Common coding errors in orthopedics include unbundling, where individual parts of a procedure are coded separately instead of using a single code designated for that area. For instance, the different parts of the knee (medial, lateral, and suprapatellar) should be bundled under a unique code for procedures performed in that area. Another error involves fracture care, where prefabricated casts or braces are incorrectly assigned codes intended for custom-made devices.
  • Long Claims Submission Process: Submitting claims quickly is a common challenge in orthopedic billing due to the complex nature of the process. Orthopedic procedures often involve multiple services, treatments, and detailed documentation, which can take time to accurately compile and organize for claim submission. Other challenges with submitting claims on time include high volumes of patients, deadlines, and gathering enough patient information before submitting the claim.
ways to improve your Orthopedic Medical Billing

How To Improve Orthopedic Medical Billing

Here are five ways to improve your orthopedic office’s medical billing process.

Train or hire an effective billing team

If you already have an in-house medical billing team, it’s important for them to understand the specific needs of orthopedic billing and stay updated on the latest codes. Consider outsourcing your medical billing to specialized companies that offer revenue cycle management solutions. These dedicated billing specialists can help optimize payment collections and minimize claim rejections, relieving your practice of the burden of managing billing processes.

Use proper code bundling

Code bundling is a billing strategy that combines services on a single bill, reducing paperwork and simplifying the billing process for patients and insurance companies. By bundling services, accurate payments can be achieved upfront, minimizing disputes between staff and patients. For example, if a patient receives a bone X-ray and subsequent treatment for a broken bone, these services can be bundled together rather than billed separately. When bundling codes, it is important to use the code associated with the more significant or complex procedure to ensure accurate billing for multiple procedures performed simultaneously.

Use modifiers

Modifiers in CPT coding provide additional details about a patient’s status or the services and procedures performed. During the global period (up to 90 days post-surgery), modifiers become particularly important because related services and follow-up procedures cannot be billed separately from the overall surgical package during this period.

Correctly using modifiers can generate revenue by accurately reflecting any changes made to a procedure due to specific factors. For example, adding Modifier 59 to a CPT code for a bilateral knee aspiration ensures that the physician is appropriately paid for performing the procedure on both knees. However, misusing modifiers can lead to audits, penalties, and lost revenue. So, it’s important to make sure your billing team is familiar with modifier and their appropriate uses.

Spot unbundling errors

Unbundling occurs when multiple separate codes are used for a procedure that should have been billed under one designated CPT code. To prevent unbundling errors, compare individual patient medical records with the doctor’s procedural notes and the codes used in billing to ensure alignment and accuracy. This verification process helps avoid unbundling mistakes and promotes proper billing practices.

Stay up to date with code changes

Staying updated on the regular updates and modifications in medical coding is essential to ensure accurate billing and compliance with the latest regulations. The American Medical Association (AMA) periodically updates E/M (evaluation and management) codes, with the most recent updates taking effect on January 1, 2023. Generally, CPT code changes are implemented annually on January 1, while ICD-10 code changes are effective on October 1 each year.

Contact Hansei Solutions

If you are interested in a medical billing company that can handle the complexities of orthopedics, contact Hansei Solutions. Our ambulatory surgical center billing team has years of experience, countless certifications and qualifications, and a deep understanding of the intricacies of orthopedic billing.

We specialize in providing comprehensive billing solutions and revenue cycle management tailored to the unique needs of orthopedic practices. Contact Hansei Solutions today to learn how our experienced team can support your medical practice and ensure optimal financial outcomes.

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