Many significant coding and billing changes have been introduced last decade for orthopedics. Keeping up with the rapid pace of change in healthcare is challenging but essential, and understanding factors like demographic shifts, technological improvements, and government initiatives are critical to the success of any orthopedic practice.
In a recent Becker's Spine Review article, Merge Solutions Manager explored a number of important trends that will impact the orthopedic market in the upcoming years.
Decades of wear and tear and the increasing prevalence of American obesity are causing increased pressure on joints, which can lead to an array of bone disorders. To give you an example low bone mass and osteoporosis are estimated to be major public health concerns for nearly 44 million US adults, and that trend is estimated to climb to 61 million by 2020¹.
Practices are being forced to consider upgrading their orthopedic solutions, or they will be faced with ongoing reimbursement cuts. Starting this year, those still using analog equipment will face a 20 percent reduction in reimbursement, followed by a 7 percent reduction in 2018 for using computed radiography instead of digital radiography.
As Americans lead more active lives, the numbers of sports injuries are also on the rise. In fact, the anticipated growth of sports and spine medicine through 2019 is 26 and 24 percent respectively. Orthopedic surgeons should be aware of opportunities in these two specialties as they plan for the future.
Declining reimbursements increased regulatory pressures, and rising costs are shaping this trend. Health systems continue to acquire smaller orthopedic practices, aiming to enhance patient outcomes and lower costs, but the impact of consolidation on clinicians, insurers, patients, and the overall health systems is still being determined.
With the transition from volume-based care to value-based care, orthopedic surgeons will be faced with pressures to cut costs while maintaining quality, amidst looming reimbursement cuts and increased patient volume. Practices will need to focus on distinguishing themselves from competing hospitals by demonstrating high-quality scores.
With the right planning, orthopedic practices can not only navigate these trends but leverage them for continued growth and success. Professional orthopedics billers and coders can tackle these challenges together with the doctor’s office.
CMS allows you to report certain codes with assistant surgeon modifiers AS, 80, 81, or 82. Medicare’s physician fee schedule relative value file includes an indicator to designate which codes may be paid for an assistant and which codes may be paid with medical necessity documentation. This is the key to documentation for the assistant-at-surgery charges. Both AAOS and AMA have indicated that documentation must include the medical necessity of the assistant and their role as documented by the surgeon. Without this information, there is no indication the assistant did more than simply observe the surgery.
X-rays and other radiology services also require significant documentation. In the 2016 CPT codebook, the AMA clarifies that radiology services require an interpretation and report. This requirement is found in CPT Assistant but was not mentioned in the CPT® codebook until this year.
Without a written interpretation and report, there is no documentation that a radiology service occurred. It may have been a review of a report, a technical component only, or a different service than billed.
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