Getting paid by insurance timely and accurately in any medical specialty including orthopedics is a vigorous process. Introduction of new billing and coding rules are a regular part in all practices, and billers and coders must aware of all coding updates, policies and conventions required for coding aptly for accurate reimbursements. There are numerous reasons due to which a claim can be denied or rejected, thereby again beginning the daunting task of rechecking claims, filing them back within a stipulated time and then waiting for reimbursements; while incorrect claims implies a loss in reimbursements after all the wait. Hence, it is imperative that orthopedics billing and coding is accurate while filing claims the first time.
Here Are Some Ways In Which Claim Denials Can Be Avoided:
Insurance Verification:
Verifying insurance of returning as well as new patients must be a mandatory rule by any healthcare facility, especially for the orthopedics department. The coverage period (dates) and the procedures/services that qualify to be reimbursed and those that are not covered in the policy must be verified beforehand. This is especially important as the patient must know the dues that need to be paid by him (copays) and the payments that would be made by insurance. Deductibles must be calculated and the copays collected when the patient visits the hospital.
Demographics:
In orthopedics, 30-40% of claims are denied due to incorrect demographics such as incorrect or missing social security number, name/address details, incorrect date or place of services rendered, or incorrect NPI of the referring/billing orthopedist, etc. Hence, these details must be checked thoroughly.
Orthopedics Codes And Modifiers:
Inapt diagnosis codes (diagnosis codes must be entered in the claim form as per the procedure performed or services rendered), new codes added/deleted/modified with respect to x-rays, reforms in knee and hip surgeries, CPT, HCPCS, ICD-10 codes if not updated and entered correctly in the claim form will definitely invite a denial from insurance payers. Similarly, using a global code with a technical modifier will ensure rejection/denial of the claim. Further, the usage of modifiers must be supported with apposite documentation.
Local Coverage Determinations:
It is suggested to keep the ‘local coverage determination’ handy for referring to the local rules and regulations regarding the carrier and if the service/item is covered/not covered on a carrier-wide basis.
Automate / Outsourcing:
Orthopedics billing and coding must be automated and/or outsourced to a third party, who are professional billers and coders and specialize in orthopedics claim billing. A computerized claims checker can be incorporated wherein claims can be screened before submission. Electronic Health Records and claims management systems can be integrated for sending claims to insurance agencies. Outsourcing agencies are experts and usually, make the best of use of technology (eg. claim scrubbing software) and manual resources to check on claims (eg. coding errors) before sending them out. With these effective systems in place, errors can be mostly eliminated.
As Per apachemedicalbilling.Com, The Most Frequent Denials Due To Incorrect CPT Codes Are:
– 20610: Aspiration And/or Injections; Major Joint Or Bursa
– 99203: Outpatient Doctor Visit, New Patient, Level 3
– 99214: Outpatient Doctor Visit, Level 4
– 99213: Outpatient Doctor Visit, Level 3
– 97110: Therapeutic Exercises
Denial Codes From The Payers For Orthopedic Billing Which Must Be Checked For Include:
- 45: Charge Exceeds Fee Schedule
- 23: Prior Payer(S) Adjudication Affected This Payment and/or Adjustment
- 18: Duplicate Claim/Service
- 59: Processed Based On Multiple or Concurrent Procedure Rules
- 223: Mandated Adjustment Code When Other Code Not Applicable
The information must be collected by the staff/outsourcing agency and processes optimized for reducing the number of claim denials. Analysis of data and identifying the root causes/patterns in denials can largely reduce their occurrence in the future. The preceding steps will ensure that an orthopedic practice gets reimbursed at the right time, significantly saving on time and money otherwise spent on such tasks.
