In California, most of the times when I am sitting in a coffee shop I unintentionally listen to some discussion of orthopedists.
Sometimes, they are not in mood and discussing about how rudely they are being treated by insurance providers.
But actually, the fault is not of the payer, but due to the orthopedic billing mistakes they commit when they are sending their claim.
And actually the fault is not theirs either. Because, they have no professional medical billers and coders who can sail their billing ship against the mighty waves of payer rules.
However, making the discussion short. Here I discuss some common medical billing mistakes usually orthopedic providers in California, and also in other states like Florida, etc., do.
Furthermore, I will also guide you how to avoid the billing mistakes if you are one of the orthopedists discussing the at coffee shop.
Top 10 Common Orthopedic Billing Mistakes
The billing mistakes are not limited to only 10. But they are the most common.
1. Wrong CPT or ICD-10 Codes
Problem:
Using wrong or outdated codes.
Effect:
Claim denial or underpayment.
How Fix:
· Use updated CPT or ICD-10 codes.
· Train your billing team
· Double-check codes before sending
It is always recommended to consult orthopedic billing expert to avoid this billing headache.
2. Unbundling Services
Problem:
Billing separate services that should be together (bundled).
Effect:
Insurance may reject the claim or reduce payment.
How to Fix:
· Know which codes are bundled
· Use code modifiers properly
· Audit claims before submission
3. Missing Prior Authorization
Problem:
Sending claims without getting approval first.
Effect:
Claim denial, delay, or patient dissatisfaction.
How to Fix:
· Check insurance plans before treatment
· Assign staff to manage pre-authorizations
· Use software to track authorization status
4. Incorrect Patient Info
Problem:
Typos or missing details like DOB or insurance number.
Effect:
Claim rejection.
How to Fix:
· Verify patient info at every visit
· Use digital forms to reduce errors
· Have a checklist for front desk staff
5. Lack of Medical Necessity
Problem:
Not showing why treatment was needed.
Effect:
Claim denial or audit.
How to Fix:
· Document symptoms and diagnosis clearly
· Match procedure codes with diagnosis codes
· Add doctor’s notes if needed
6. Overbilling or Upcoding
Problem:
Charging for more than what was done. For example, the allowed amount for a procedure is $60 and you charge $130. Even more than double, it can make you vulnerable to audits and penalties.
Effect:
Fines, audits, or legal trouble.
How to Fix:
· Be honest and accurate
· Train staff to avoid overcoding
· Use internal audits
7. Late Filing of Claims
Problem:
Sending claims after the timely filing limit.
Effect:
Automatic denial.
How to Fix:
· Know payer deadlines (some are 30 days!)
· Submit claims daily or weekly
· Set reminders for your team
8. Not Following Payer Rules
Problem:
Ignoring rules that vary by insurance.
Effect:
Denied or delayed payment.
How to Fix:
· Keep a guide for each payer
· Use clearinghouses to check rules
· Subscribe to payer newsletters
Pro Tip: Use CMS.gov for the latest official code updates.
9. No Follow-Up on Denied Claims
Problem:
Giving up on denied claims.
Effect:
Lost revenue.
How to Fix:
· Assign staff to track denied claims
· Appeal with proper documents
· Use software with denial tracking
10. Poor Communication Between Staff
Problem:
Front desk, providers, and billers not sharing info.
Effect:
Missing data or wrong codes.
How to Fix:
· Hold weekly team huddles
· Use shared software
· Create a flowchart for billing steps
Common Billing Mistakes and Their Fixes
The table below will clear your mind in just a glance.
| Mistake | Result | Fix |
| Wrong Codes | Denials or underpay | Use updated code books |
| Unbundling | Reduced payment | Learn bundling rules |
| No Authorization | Denials | Get approval before treatment |
| Patient Info Errors | Claim rejections | Double-check every visit |
| No Medical Necessity | Denials or audits | Add complete documentation |
| Upcoding | Legal risk | Train staff properly |
| Late Filing | Denials | Set claim submission schedules |
| Ignoring Rules | Payment delays | Stay updated with payer guidelines |
| No Claim Follow-Up | Lost revenue | Track and appeal denied claims |
| Poor Communication | Coding errors | Weekly team meetings |
Final Thoughts
Orthopedic billing may seem hard, but it’s easy to fix mistakes once you know what to look for.
A few smart steps can save you a lot of time and money.
Keep your team trained, follow the rules, and don’t wait to fix issues
Let me tell you a simple solution. However, orthopedic billing is not a rocket science. You can do it with your in-house team. But I would like to suggest you to outsource you billing services to some third party billing expert and focus on your core goal that is providing the best healthcare services.
FAQs
In your mind, if you have these questions, here are clear answers:
Why billing mistakes happen?
Many things can go wrong in billing.
Here’s why mistakes are common:
· Fast-paced clinic work
· Lack of billing staff training
· Wrong codes
· Poor record keeping
· Outdated software
· Not following insurance rules
Who Is This Guide For?
This blog is for all types of healthcare providers in California:
· Small orthopedic clinics
· Solo practitioners
· Group practices
· Large hospitals
· Physical therapy centers
No matter your size, this guide is for you.
What Is Orthopedic Billing?
Orthopedic billing is the process of sending insurance claims for bone and joint care.
It includes procedures like:
· Joint replacements
· Fracture care
· Spine treatments
· Sports injuries
· Physical therapy
Each procedure has codes.
These codes must be right.
If not, you lose time and money.