You know that billing in orthopedics is different from billing anywhere else. With complicated CPT codes and payer-specific quirks regarding implants and prior authorizations as well as surgical bundling, orthopedic billing is one of those specialties that can be difficult to master.

Many practices attempt to do this themselves with a general billing setup. However, they soon discover that the “general” knowledge of billing is not enough when dealing with joint replacements and spinal procedures. Specialized orthopedic medical billing is no longer a luxury, but a necessity.

This article will explain why orthopedic billing is so complex, what the most common billing mistakes are, and how specialized billing solutions can make the difference between an uphill battle and a revenue cycle that’s healthy.

What is Orthopedic Medical billing?

The process of orthopedic billing involves translating orthopedic diagnoses and procedures into codes that are accurate for insurance reimbursement. This can cover anything from a simple fracture to a complicated joint replacement surgery. This job is at the intersection between orthopedic billing and coding knowledge, insurance policies, and strict compliance regulations.

In contrast to primary care billing orthopedic claims can involve multiple procedures in one visit, implants, hardware and long-term post-operative care. All of these need to be properly billed to avoid denials.

Why is Orthopedic billing so complex?

High Volumes of CPT Specialized Codes

The billing of orthopedic CPT codes covers a wide range of fracture care, arthroscopy and spinal fusions, as well as total joint replacements. These codes may have modifiers, bundling and global period considerations which a general biller might not understand.

Global Periods and Surgical Bundling

Orthopedic surgery often comes with a global period of time set during which the follow-up treatment is not separate billable, but considered a part of original procedure. One of the leading causes of claims being denied or not paid is due to a misunderstanding of these time windows.

Frequent Authorization Requirements

Prior authorization is required for certain orthopedic procedures, including imaging, surgery, and injections. In this specialty, claim rejections are often due to missing or delayed authorization.

ICD-10 complexity for Orthopedic Surgery

ICD-10 codes for orthopedic surgery require specific details about the injury (left or right), as well as the type of encounter (initial, sequela, or subsequent). An automatic denial can be triggered by a small coding error.

Common Orthopedic Billing Errors

Even the best-run businesses can run into problems. Among the most common:

• Use of modifiers incorrectly on claims for multiple-procedure
• No prior authorization required for surgery or imaging
• Billing errors for global periods: Follow-up visits are billed separately, when they shouldn’t.
• Incomplete documentation medical necessity especially for implants
• Laterality error in ICD-10 Coding
• Old fee schedules which do not reflect current payer agreements

All of these situations can lead to a claim being denied. When they occur repeatedly, the revenue from your practice is slowly eroded.

The real cost of billing errors for Orthopedic Practices

It is easy to underestimate the cost of a few billing mistakes. Denied claims can lead to delayed payments, extra staff time spent on appealing, and, in some cases revenue that is written off because the appeal period has passed. Even a denial rate of 10-15% can result in significant revenue delays or lost for a practice that performs dozens of procedures per month.

Specialized billing for Orthopedic Practices: Benefits

Fewer Claim Denials

Specialized medical billing staffs understand the coding rules for orthopedics, bundle logic and payer quirks. This translates into cleaner claims with fewer orthopedic rejections.

Faster reimbursement

Payment cycles are shorter when claims are submitted correctly on the first try. This means a more stable and predictable cash flow, instead of revenue being tied up in appeals or resubmissions.

Stronger Compliance

Payers will continue to scrutinize documentation more than ever before in order to ensure compliance with orthopaedical billing. Specialized billing teams stay up to date on the changing requirements, so that your practice does not fall behind.

More time for patient care

Your staff can concentrate on patient care and practice expansion when they aren’t bogged down in denials appeals and coding errors.

The Bigger Picture of Orthopedic Revenue Management

The revenue cycle management of the orthopedic industry includes billing, but it also includes:

• Verification of eligibility before appointment
• Charge capture during and after procedure
• Claim submission within time
• Tracking and resolution of Denials
• Posting and reconciling payments

These pieces working together seamlessly can lead to measurable revenue growth for practices. Not because they see more patients but by capturing revenue that’s already theirs.

Should you outsource orthopedic billing?

Signs That It Could Be Time

• You feel that your denial rate is consistently high and are not sure why.
• Billing consistency is affected by staff turnover
• Spending more time on billing software than patient care
• The need for prior authorizations keeps slipping by

Benefits of Outsourcing Medical Billing

When you outsource your orthopedic billing, you can expect to gain access to coders that specialize in CPT and ICD-10 orthopedic codes, relationships with payers and systems designed to prevent denials rather than simply manage them. With a specialized partner on board, many practices find that the integration of orthopedic EHR billing is much smoother. Claims are generated directly from clinical documentation and there is no need for manual re-entry.

What to look for when choosing an Orthopedic Billing Company

Not all billing companies are created equal. Look for these things when evaluating a billing company that handles orthopedic billing:

• Experience in billing and coding orthopedics
• Transparent reporting of denial rates and revenue trends
• Communication and turnaround times are important
• Compatible with existing medical billing software that orthopedic practices use
• Not just processing denials but also the number of them has been reduced.

Improve Orthopedic billing starting today

Before bringing in external help, practices should tighten their processes by:

1. Auditing recent denials in order to identify root causes
2. Checking for gaps in the prior authorization workflow
3. Coders must be current with the latest CPT/ICD-10 updates
4. Verifying eligibility for benefits and services before each procedure
5. Key metrics such as the first-pass acceptance rate can be tracked.

Even before you consider outsourcing, these steps can reduce billing mistakes that orthopedic practices often make.

Partnerships for better Orthopedic Billing Results

It’s not by chance that orthopedic billing improves. It takes specialized expertise, consistent processes and a team who understands the specialty inside out. We work with orthopedic practices at QHS Health to help reduce denials and tighten documentation gaps. This allows your team to spend more time on patient care and less time on paperwork.

Frequently asked questions

1. Why is orthopedic billing more complicated than general medical billing

General billing knowledge is often inadequate to cover the complex aspects of orthopedic billing, including surgical bundling and global periods, implant documentation and CPT and ICD-10 codes.

2. What are some of the most common billing errors in orthopedics?

Modifier errors, missed prior authorizations and global period billing mistakes are some of the most common.

3. How can orthopaedic practices reduce the number of denied claims?

Denial rates can be reduced by ensuring eligibility up front, obtaining prior authorizations as early as possible, and using coders who are experienced in orthopedic billing.

4. Outsourcing orthopedic billing is it worth it for small practices?

Yes, for many smaller practices the savings in administrative work and denials often outweigh the costs of a billing partner.

5. What should I be looking for in an ortho billing company?

Consider software that has proven orthopedic experience, transparent reporting of denials, and compatibility to your current EHR/billing software.

Are You Ready to Improve Your Orthopedic Billing System?

Delay in reimbursements and denied claims shouldn’t be a part of business. If you’re ready to improve cash flow and reduce errors in your orthopedic practice, QHS Health offers a free billing evaluation Find out where orthopedic medical billing can make the most difference in your practice.