The 5 Most Common Mistakes of Claims Denials in Orthopedic Billing

January 13, 2015

As per the 2012 AAOS Orthopedic Surgeon Census, there were around 27,733 orthopedic surgeons on record in the US. The Association of American Medical Colleges has predicted a shortage of 46,100 surgeons / specialists in the US by 2020. Meanwhile in orthopedics, specifically in spine and pain management, the industry is experiencing considerable erosion in incomes.

Orthopedic billing services will play a pivotal role in determining the shape of the industry as there is a shortage of surgeons in US and at the same time a phenomenon of erosion of income. It is important to identify the common mistakes of claims denials in orthopedic billing in order to prevent them in real-life scenarios.

Here are the five most common mistakes of claims denials in orthopedic billing:

  • Incomplete or Inaccurate Insurance Information
    This is the most common mistake which results in denials from payers. The patient's name could be spelled incorrectly in the medical records. There are also possibilities of a mismatch in the patient's date of birth or gender selection. There could be instances of missing or invalid subscriber number or insured group number. The in-house billing staff may not be competent enough to capture these details perfectly which could lead to claim denials.
  • Claims Not Filed on Time
    Orthopedic billers should aim to submit claims as soon as possible so that they don't miss the payers' deadlines. Another point to be noted here is that different payers have different deadlines. Billers should keep a list of general payer deadlines handy. They should track and document each payer’s receipt of claim submissions.
  • Preauthorization
    According to an AMA survey, nearly 64% of physicians report that it is difficult to determine which tests and procedures require preauthorization by insurers. Many orthopedic surgeons lose out on their claims settlement by failing to abide by the preauthorization requirements of insurers. An outsourced orthopedic billing service provider can make a list of the tests, treatment and payers that require authorizations. When the service or treatment is prescribed, they can check the list to determine whether or not preauthorization is necessary.
  • Incomplete Codes
    Frequent updates in codes make collecting reimbursements and appealing denials a constant struggle. It is essential that whatever is documented is billed. If a procedure is not documented, payers consider that the procedure was not performed by the orthopedic surgeon. If billers are using outdated CPT, ICD-9 or HCPCS codes, there are high chances of claims being denied by the payers.
  • Upcoding or Unbundling
    Use of CPT codes to bill a payer for providing a higher-paying service than what was actually performed is called upcoding. Unbundling occurs when charges that normally fall together under one billing code are listed separately. Upcoding or unbundling of the service performed result in denials from the payers.

MedicalBillersandCoders.com can help orthopedic surgeons reduce their denials rate. Their team of expert professional billing specialists identifies the reasons behind claims denials and analyzes what will boost the RCM. MBC works on the in-house billing process to maximize reimbursements. Their coders’ expertise includes the ICD-9-CM, E/M and ICD-10 coding standards. Outsourced orthopedic billing services can enable orthopedic surgeons take advantage of the current situation with minimum claim denials and AR follow up.


Category : Accounts Receivables / Claims Denials