Orthopedic billing services are a must to make sure that practices are getting reimbursed for services provided. The range of orthopedic treatments, from knee replacements to post-surgical therapy, can be complex, and medical billing services for them are no different.
Errors in billing work as a double-edged sword. They ultimately lead to denied claims, delayed payments, audits, and revenue loss.
With the advancement of the healthcare industry, orthopedic practices should stay ahead of the current billing regulations and standards. Many practices are still making easily avoidable mistakes.
In this detailed guide about orthopedic medical billing, Prime Well Med Solutions will talk about the top five mistakes in orthopedic medical billing and how to avoid them. Remembering these issues can help your practice bill more effectively and avoid financial pitfalls.
Let’s get started!
5 Common Mistakes in Orthopedic Medical Billing and How to Avoid Them?
Mistake #1: Wrong Use of Modifiers
These modifiers are crucial in orthopedic medical billing. They provide clarification as to when a procedure has been modified in some manner. They are used to give insurance carriers more details about a service that was performed, which might be related to a procedure’s complexity, location, or frequency.
Modifiers used more often in orthopedic medical billing:
- Modifier-22: Increased procedural services
- Modifier-59: Distinct procedural service (to report that a procedure was distinct from others performed on the same day)
- Modifier-50: Bilateral procedures (for bilateral surgeries)
- Modifier-78: Return to the operating room for the related procedure on an unplanned basis
Why it’s costly:
Using the incorrect modifier, whether it’s one that doesn’t apply to the procedure or one that is necessary to get the claim paid correctly, will result in a denial or underpayment.
For example, inappropriate use of modifier-59 can imply that the procedures were performed separately when they weren’t, which may lead to a claim denial.
How to avoid it?
The first thing to do to prevent mistakes with modifiers is to train properly. The team for best orthopedic medical billing must have knowledge of different modifiers. Medicare and other insurance carriers should be reviewed regularly. Also, make sure your team knows when to use modifiers correctly and how to use them.
A review process for verifying claims before submission would catch any modifier errors at an early stage.
Mistake #2: Underbilling or Overbilling Procedures
Over and underbilling are two sides of the same coin in orthopedic medical coding. Underbilling is when a procedure is coded at a lower level of service than was actually conducted. Billing for a higher reimbursement code for a procedure than was actually done is overbilling.
Why it’s costly:
If you underbill, you are losing revenue to the practice because the amount paid by insurance will be lower than the amount due. This may seem counterintuitive, but improper underbilling, dollar for dollar, can become quite expensive when it happens regularly.
Overbilling, on the other hand, is far more dangerous in orthopedic medical billing because it can trigger audits, fines, and legal liability. For instance, a surgeon might mistakenly overbill for a complex spinal surgery by using an incorrect CPT code. This error can lead to an audit with serious repercussions for the practice, especially if CMS becomes involved.
How to avoid these orthopedic medical billing mistakes?
Accurate and consistent medical coding ensures that you can avoid underbilling or overbilling. Institute a policy for double-checking codes before submission, and get every billing team member trained to distinguish between CPT codes.
Using orthopedic billing software can also reduce common coding errors by recommending the correct codes based on the information provided. Partnering with a billing company that has expertise in orthopedic-specific billing can also ensure that the care your practice provides is consistently compensated appropriately.
Mistake #3: Failing to Pre-Authorize
Many orthopedic treatments, particularly surgeries, require prior authorization from the patient’s insurance company. Joint replacements, spinal surgeries, or imaging tests may not be covered unless pre-authorization is secured.
If this approval is not obtained before treatment is provided, or for some reason, the payer denies authorization or reduces reimbursement, the practice has to absorb the cost.
Why it’s costly:
If pre-authorization isn’t obtained, insurance companies may refuse to pay, even if the treatment is medically necessary. That could leave the patient on the hook for the whole bill, creating a burden and dissatisfaction. In addition, the practice may be forced to write off the charges and lose revenue.
How to avoid it?
Avoid this mistake by making sure you have a clear process in place to ensure that you get pre-authorization for any procedures that require it. In orthopedic medical billing, having a checklist for every patient procedure is essential to determine if pre-authorization is necessary and to confirm that it has been received before proceeding with treatment.
Assign a team member the responsibility of monitoring the status of authorizations and submitting the necessary requests in a timely manner. For high-volume practices, implementing an automated system for checking pre-authorization can eliminate or significantly reduce the time spent on this task, improving efficiency in orthopedic medical billing.
Mistake #4: Lack of Proper Documentation
Orthopedic medical billing needs precise and complete documentation. Lack of documentation, for example, if you do not include details of the procedures you performed, leads to billing errors and denials. Documentation is proof that what was done and billed for was considered medically necessary and that the correct codes were billed.
To prevent, the most common documentation mistakes are:
- Not including the physician’s signature
- Failure to give a complete or clear explanation of the procedure
- No dates, or wrong provider info
Why it’s costly:
Poor or incomplete documentation increases the chance of claims being denied. Not enough documentation can mean the insurance company denies the claim altogether or cuts down the reimbursement. In turn, something like poor documentation can trigger poor audits, which can lead to greater scrutiny and potentially very significant financial penalties.
How to avoid it?
Train all healthcare providers and billing staff regularly to ensure accurate documentation for billing purposes. Set guidelines for reporting procedures and ensure all important information is covered.
Use EHR or billing software that streamlines documentation and enables billing compliance. Also, encourage your team members to re-check the documents before they submit the claims, to make sure every signature and date, as well as the provider name, is accurate.
Mistake #5: Not Keeping Up with Changes in Coding
CPT codes, more specifically, are updated regularly to incorporate new procedures, varying treatment protocols, as well as the latest advancements in medical technology. In orthopedic medical billing, these coding changes may include new codes for joint replacements, arthroscopies, or other specialized treatments.
Staying current with these updates is essential for accurate billing and maximizing reimbursement.
Why it’s costly:
You may be able to use your updated and correct codes to address or even prevent claim denials and/or delays in reimbursement. If a new CPT code is launched for a hip replacement but the old code is still in use, and the old code is filed, the insurance provider may deny the claim.
Using outdated codes can also undermine your ability to negotiate higher compensation with insurers, as can providing “bundled” services.
How to avoid it?
Have the billing team on the lookout for updates from the AMA, CMS, and other pertinent organizations. Updates to coding guidelines occur regularly and you need to train your staff on new codes in a timely manner.
Another way to keep your billing codes up to date is to use software that automatically updates codes in accordance with regulatory changes.
Final Thoughts
Orthopedic medical billing is a complicated process and even minor mistakes in orthopedic billing services can accumulate. It affects your practice’s revenue. If you stop making these five common mistakes discussed in this guide, you can maximize billing processes, reduce claim denial, and ensure your practice gets reimbursed fairly and timely.
A good orthopedic medical billing partner can help simplify your process, minimize errors, and keep you compliant with the ongoing changes made to regulations.
So, do you want to streamline your billing process? Contact us now!
