Orthopedic medical billing is an essential factor in maintaining and improving revenue cycle management at orthopedic clinic. After providing care services to patients, it becomes a headache for orthopedics to get their reimbursement from patients and insurance providers. So, orthopedic billing involve the process of creating bills after care services are provided to patients, submitting the bills also called claims to insurance providers or sending them to out-of-network patients to get payment as reimbursement.
Healthcare practices have specialized persons for these specific tasks, but handling them to some third-parties billing companies can really bring fruitful results as they have professional and expert team of billers and coders.
In this comprehensive article, we will discuss about orthopedic billing, its process, key components of orthopedic billing, and common challenges healthcare provider face during the process of orthopedic medical billing and their solutions.
Here are some challenges which usually healthcare practice face during the process of orthopedic billing and coding.
Orthopedic Billing & Coding Challenges & Solutions
Orthopedic billing and coding come with many challenges due to the complexity of procedures, frequent updates to coding guidelines, and the need for precise documentation. Addressing these challenges requires robust software solutions, continuous education for coding staff, and adherence to payer-specific guidelines. By implementing these strategies, practices can improve efficiency and reduce errors in billing and coding processes, and improve revenue by receiving reimbursement on time.
Complexity of Procedures and Multiple Codes
Orthopedic procedures often involve multiple treatments and surgeries, requiring the use of various billing codes.
Solution: Implement robust billing software that can handle multiple codes and cross-references them accurately. Regular training for coding staff on how to manage complex cases and staying updated to latest trends in healthcare industry is also essential.
Proper Use of Modifiers
Correctly applying modifiers for specific situations, such as bilateral procedures or multiple procedures during a single session, can be tricky.
Solution: Provide detailed training sessions focused on the appropriate use of modifiers. Utilize coding manuals and payer guidelines to ensure correct application, and have a quality control process in place to review and correct modifier usage.
Frequent Updates to CPT Codes
Keeping up with the constant updates to the Current Procedural Terminology (CPT) codes is essential but challenging.
Solution: Stay current with industry changes by subscribing to coding updates, attending workshops, and participating in webinars. Regularly update your billing software and provide continuous education for the coding team.
Payer-Specific Guidelines
Different insurance payers have their own guidelines, which can vary and complicate the billing process.
Solution: Maintain a comprehensive database of payer guidelines and regularly review it to ensure compliance. Have a designated staff member or team responsible for staying updated on payer-specific changes and communicating these updates to the rest of the team.
Documentation and Accurate Medical Records
Ensuring that documentation is clear, complete, and accurate is crucial for proper coding and billing.
Solution: Implement thorough documentation practices and regular audits to ensure accuracy. Train healthcare providers on the importance of detailed and clear documentation. Utilize electronic health record (EHR) systems to streamline the documentation process.
Handling High Volume of Claims
Orthopedic practices often deal with a high volume of claims, which can be overwhelming and increase the risk of errors
Solution: Automate as much of the billing process as possible with advanced billing software to manage large volumes efficiently. Hire additional staff or outsource to professional billing services during peak times to manage workload effectively.
Orthopedic Medical Billing Guidelines
Effective orthopedic medical billing involves a series of important steps to ensure accuracy and timely reimbursement. Additionally, outsourcing to specialized billing experts can significantly streamline the process, allowing practices to focus on patient care while enhancing revenue and reducing administrative burdens. Orthopedic billing expert can help you in all your process of orthopedic medical billing and coding. Here are some guidelines to follow.
Insurance Coverage Verification
Ensuring and verifying all insurance-related aspects is crucial in orthopedic billing. Services should only be provided to patients with pre-authorized and verified insurance coverage. It is also important to confirm with insurers whether they cover the expected services to avoid issues later on.
Accurate Patient Information
While it may seem basic, double-checking patient details such as name, address, contact information, and demographics is vital. A single error in patient information can lead to claim denials. Ensure your administrative staff is meticulous in verifying and recording every piece of patient information accurately.
Timely Claims Submission
Submitting billable claims on time is essential. Practitioners should create a standard process, adhere to regulated procedures, and follow popular metrics to improve the claims submission process. Be aware of claim filing timelines and limitations set by different insurance payers to avoid denials.
Specific and Accurate Coding
Claims need to be specifically coded to avoid denials. Ensure your practice has all the necessary information about codes and what diagnoses they cover. The upgraded ICD-10 codes require accurate coding for timely payments. Equip your billing staff with the essential knowledge and resources to document claim codes efficiently.
Consider Outsourcing When Necessary
When managing billing costs becomes challenging, consider outsourcing to specialized orthopedic medical billing experts. Outsourcing can save time, reduce stress, and resolve billing and claiming problems efficiently. It ensures continuous claim and billing processes even during staff turnover or absences, ultimately enhancing revenue and profitability.
CPT Codes Used in the Orthopedic Medical Billing
CPT (Current Procedural Terminology) codes are essential for accurately documenting and billing orthopedic medical services. These codes help ensure precise documentation and proper reimbursement for the services provided. Here are some commonly used CPT codes in orthopedic medical billing:
Evaluation and Management (E/M) Codes: 99201-99499 – Used for patient visits, examinations, and treatment planning.
Anesthesia Codes: 00100-01999, 99100-99140 – Cover anesthesia services during surgical procedures.
Surgical Procedure Codes: 10021-69990 – Encompass various orthopedic surgeries, from simple repairs to complex joint replacements.
Radiology Codes: 70010-79999 – Used for imaging services such as X-rays, MRIs, and CT scans.
Pathology and Laboratory Codes: 80047-89398 – Represent laboratory tests and pathology services for diagnosis and treatment planning.
Medicine Codes: 90281-99299, 99500-99607 – Cover various medical services not categorized elsewhere, such as injections and wound care.
Hand Surgery Codes: 11760 – Repair of the nail bed, 25215 – Carpectomy (removal of all proximal-row bones), 64721 – Neuroplasty (carpal tunnel release), 29848 – Endoscopic carpal tunnel release.
Fracture Care Codes: 29000-29085 – Cover initial and subsequent fracture care, including casting and splinting.
These codes help streamline the billing process and ensure accurate claims submission, leading to timely reimbursements for orthopedic practices.