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You treat patients with care 24/7 in your orthopedic practice. But, despite your tireless services and excellent care, you are not getting the revenue that you should be. There could be tens of reasons for this, but the biggest culprit is insurance claim denials.
What makes denials more frustrating is that they are often caused by just minor, negligible mistakes. Insurance providers just need a reason to reject your payments, and these mistakes are a golden opportunity for them. Up to 80% of medical claims contain errors, contributing to billions in lost revenue each year.
After serving tens of orthopedic practices as a billing consultant, we have created this guide to educate you on the common billing mistakes that all of these practices share. So, let’s start.
Incorrect CPT Codes And Modifiers
This is no secret; orthopedic procedures involve some of the most complex coding in healthcare. Arthroscopic repairs, joint replacements, and procedures with imaging requirements are all complex and interconnected, and can confuse any biller. Even minor differences in the service can require a completely different code.
The American Medical Association reports that coding errors account for 7% to 12% of claim denials in orthopedic practices.
Modifier errors prove particularly expensive. For example, many new billers still use modifier 59 in most situations; however, Medicare and other big insurance providers have clearly stated that modifier 59 should only be used when no other modifier explains the situation. The priority should be given to modifiers XE, XU, XU, or XP.
Another frequent issue involves fracture coding. When practices fail to distinguish between open and closed fractures or miss the specific anatomical location requirements, claims face immediate rejection. This becomes especially problematic with complex cases involving multiple fracture sites.
Inadequate Documentation of Medical Necessity
Documentation is the most important part of any claim, probably even more important than the CPT codes. Without proper documentation, you can not justify why a provided service was necessary. No or inadequate documentation means straight denial.
Each insurance company maintains specific medical necessity criteria for orthopedic procedures. So, before filing the claims, always make sure to check the exact documentation requirements of the relevant insurance provider.
For instance, for joint replacement surgery, insurance companies usually require documentation of conservative treatment failure and imaging tests that clearly show the issue. Missing any one of them can trigger an immediate denial.
Prior Authorization Challenge
In orthopedic medical billing, most of the procedures are surgical. Plus, a lot of these surgical procedures are major and have high reimbursement amounts. This makes them particularly important for insurance companies. That’s why, in most cases, pre-authorizations are required.
When your billers forget or fail to get the pre-authorizations for major surgeries, your claims are denied. If you look at it from a wider perspective, this issue is deeply related to the documentation hurdles. The best way to deal with this is to create standard documentation templates and SOPs for high-value claims.
Then train your billing staff on these SOPs and the billing requirements of all the major insurance companies. Start with big companies like Medicare, Medicaid, and BlueCross BlueShield, then move to small payers.
Missing Submission Deadlines
Filing your claims on time is vital if you want reimbursement for your services. Failure to submit the claims before the deadline is an invitation to the providers to deny your claims.
While this can vary from time to time, here are some general deadlines. Medicare requires claim submission within 12 months of service, while many commercial payers enforce 90-day deadlines.
One exception in this scenario is claims for workers’ compensation and personal injury cases. Insurance companies often allot extended deadlines for these claims.
Even a single missed deadline on a major joint replacement procedure can cost practices thousands in lost revenue. So, always try to submit your claims as soon as possible. Try to do it on the same day if you can. But in general, you should aim for a benchmark of 1 week at most. Establish systematic claim submission workflows with built-in deadline tracking.
Wrapping Up
Orthopedic billing is a very complex field. Without experience and expert billers, you are sure to get tons of denials. Your orthopedic practice deserves every dollar it earns. So, don’t let your revenue hang in the balance.
Try to avoid the billing mistakes that we shared in this guide. However, if you are facing frequent denials and not meeting your revenue targets, we advise you to acquire medical billing and coding services from a reputable company. Getting help from these third-party companies might feel like another expense, but trust us, it will turn out to be a very beneficial decision in the long run.
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