Billing Guidelines for Orthopaedic Physicians

Orthopaedics is the branch of medicine that deals with conditions related to the musculoskeletal system, which includes bones, ligaments, muscles, joints, and tendons. These conditions might be age-related, a result of an injury, or something present from birth.

Orthopaedic billing is quite complex compared to other specialties and has a high ratio of rejected or incorrect claims. Almost 35% of claims are reported to be incorrect and 25% of the claims get rejected, which makes it even more important to understand the guidelines for Orthopaedic billing. The medical billers need to know to code, understand the whole billing process, and keep specific guidelines in check.

Here are a few guidelines one needs to follow in Orthopaedics.

Code as Specific as Possible

Orthopaedic practices involve different clinical activities:

  • Surgical like joint reconstruction and ankle, spine, shoulder, elbow, hand surgeries
  • Non-surgical like kinesiology, physiotherapy, chiropractic, or occupational therapy

These procedures cost quite a lot and inaccurate coding can cause huge problems and losses. 

You need to keep your Orthopaedic billing and coding compliant with the new system and standards of ICD-10 or else, it can get very difficult during payments for your services. There are new changes to the Current Procedural Technology (CPT) code set every year. The ICD-10 has had a significant effect on Orthopaedic coding and billing because fields like site specificity, place of occurrence, type of encounter have been added.

The CPT codes are 5 digits and can be found abundantly in this field. The codes describe conditions like ACL reconstructions, joint aspirations, injections, etc. These codes are defined with a 2-digit code known as a modifier. Your practice also needs to have quite a lot of information that justifies the codes selected.

Assign the Correct Codes

Billing codes are extremely important if you need your organization to get the right reimbursement from the insurance company for your services. These codes are defined by the ICD-10 which consists of codes for all diagnoses, procedures, and medicines used for patients. The codes are 7 alphanumeric characters that define each treatment.

Some examples of important codes:

The usage of the KX modifier is mandatory for CPT code A5500 (diabetic shoe fitting) and code L3030 (foot inserts removable). E.g.: You need to use L3030LTKX to note foot inserts removable procedure for the left foot and L3030RTKX for the right foot.

You also need to understand some exceptions. While you’re billing for CPT code 97597 (removal of devitalized tissue) for up to 20 square centimeters, you need not apply the LT or RT modifier.

Remember to add codes for everything, like codes for injections. 20600 for small joints, 20605 for medium joints, 20610 for large joints, 27096 for Sacroiliac joint, 20550/20551 for tendon injections, 20552/20553 for muscle injections.

Verification of Insurance

Save time and money by verifying insurance coverage earlier on. This will prevent denials or other issues later. Your Orthopaedic practice should be pre-authorizing and verifying coverage provided by several insurance carriers so that every patient can get active courage on the service he/she is availing. Also, you need to learn how to read the reports correctly that the insurance company sends to you. You’ll understand how to interpret if the policy covers reimbursement for your services or not.

Check Patient Information

It might sound obvious, but this is crucial in any practice. Double-check the spelling of your patient names, their demographical details, and their birth date. This might seem very repetitive but any mistake in this can lead to rejected claims.

Timely Claiming of Files

 File your claims on time to avoid any confusion later. You can create a standard process to ensure that claims are submitted in time and hence, you also need to be well-versed with the deadlines and limitations for different insurance carriers.

Analyze and Follow Up on Pending Payouts

It is important for you and your staff to know the most common reasons for denial of claims, and to avoid making them. One reason responsible for denied claims is that the charge may exceed the fee schedule, so you need to keep an eye on that. The practice of regular reporting (daily, weekly, monthly) and timely audits can help keep track of the pending claims.

Last but not the least, you can try outsourcing for these billing procedures. This will save your staff’s time and make sure that your claims are properly filled and taken ahead. 24/7 Medical Billing Services is a team of experts that can help you in streamlined coding and impeccable billing, which can help improve your revenue management cycle.

Read more : Top CPT Codes And Modifiers For Orthopaedics Billing Services

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