Responding To Growth-Induced Orthopedic Medical Billing Needs with Specialist Intervention

Orthopedics have been on upward growth trajectory thanks to a host of conducive factors – continued pro-orthopedic Medicare reimbursement reforms, innovative care procedures, breakthroughs in orthopedic technology and anesthesia administration have largely been responsible for upsurge in practice volumes. The combination of these factors has enabled shifting orthopedic from hospital-based inpatient form to a more popular and affordable form – outpatient or ambulatory settings. It is noteworthy that this form of orthopedic care is currently growing at over 20%, which is comparable with other fastest growing specialties.

While orthopedic practitioners have reasons to be upbeat about their practice prospects, they should equally be cautious and prepared for billing complexities that may be accompanying the swelling practice volumes.

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One of the primary reasons why Orthopedic Billing may be susceptible to billing complexities is that orthopedic comprises a broad spectrum of procedures to treat a variety of orthopedic conditions, which are perceived and valued differently by payers. Therefore, it would require orthopedic practitioners to be versatile to respond with orthopedic billing and coding in conformity with individual perception of the payer who they are submitting their claim to. More than mere submission of claims, they should necessarily have a systematic Revenue Cycle Management with comprehensive processes such as coding, charge posting, claims filing, payment posting, A/R follow-up including denial management, and reporting.

Significantly, insurance underpayments, which are more rampant in orthopedic and as high as 10 to 15% of the actual claims, may push orthopedic practices into a state of revenue erosion that could jeopardize their clinical and operational efficiency. As a result, they might have to emphasize on monitoring and minimizing underpayments with an effective process of credentialing, verification, patient eligibility, and proper coding & billing.

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Coding revisions too would substantially add up to Orthopedic Billing woes – with the on-set ICD-10, orthopedic codes will be more complex, detailed, and numerically too many to code a wide array of orthopedic procedures such as bone graft, open surgical partial removal of collar bone, partial repair or removal of shoulder bone, open repair of rotator cuff, open repair of rotator cuff, reconstruction rotator cuff, open repair elbow fracture involving ulnar bone, wrist fracture pinning through skin, open surgical treatment wrist fracture, shoulder scope, repair cartilage tear, shoulder scope, partial removal collar bone, shoulder scope, bone shaving, shoulder scope, rotator cuff repair, injection of lower back joint, and many more. This monumental coding revision might warrant appointment of specialist coding professionals.

The changing orthopedic coding and billing landscape would require, among various other things,

To evaluate where you stand currently as against the projected requirements for a comprehensive orthopedic RCM comprising coding, charge posting, claims filing, payment posting, A/R follow-up including denial management, and reporting.

To earmark resources to monitor finances, and assigning them the responsibility of meeting with patients before admission to pre-collect copays, deductibles and co-insurance amounts, and work out payment plans as needed.

To improve front-end revenue cycle management, comprising checking coverage and verifying patient information before hand.

To facilitate training coders on coding revisions as and when they happen.

As in the case of most busy and critical medical disciplines, orthopedics may also be bound by an overriding clinical focus that may be limiting their exposure to full-pledged orthopedic medical billing reforms. Medicalbillersandcoders.com – having successfully mediated resource-deployment for growth-induced medical billing requirements across the broad spectrum of medical disciplines – offers to replicate it in orthopedics too. With an affiliation with chosen pool of orthopedic medical billing specialists across the 50 states in the U.S., orthopedics can expect to have instant access to specialist medical billing services.

Insurance Underpayments, the Issue That is Plaguing Orthopedic Billing the Most

Insurance underpayments continues to be a major concern for medical practices across the United States; more so for orthopedic surgeons, who, despite serving in a more critical specialty, find it hard to fully recover their medical cost. Because most of the orthopedic procedures happen to be highly expensive, even a marginal percentage of insurance underpayments might turn out to be a major drain on practitioners’ revenue, which could severely spoil clinical and operational efficiency. With orthopedic surgeons’ insurance underpayments touching an all-time high of 10 percent and potentiality to reach 20 percent, it may be time that orthopedic surgeons relooked at their medical billing practices and process, and aggressively track and resolve their underpayments. It is encouraging that significant portion of these underpayments (as high as 7 to 10 percent) can easily be made good with a refined and robust orthopedic-specific medical billing.

While most of the underpayments may be linked to refusal by the insurance carriers, the root-cause may be inherent in orthopedic surgeons’ medical billing policies and procedures: Orthopedic Billing

To begin with orthopedic surgeons may have not been enrolled and approved by insurers.

They may not have taken due diligence in verifying patients’ eligibility for services prior to the actual appointment; there could have been lack of technology integration with practice management system to verify coverage for patients’ orthopedic procedures.

Orthopedic surgeons may have not been cautious in seeing pre-authorization or precertification, in the absence which payers are automatically authorized to reject payments for  procedures and services even if they have been proved to be medically necessary.

Orthopedic surgeons’ staff may have left deductible or coinsurance uncollected from patients.

Major portion of patients may have been Medicare and Medicaid beneficiaries, whose reimbursements are lower than most of the popular commercial insurance plans.

There could have been coding errors (either under-coding or over-coding) due to coding staff’s incompetence. And with orthopedic coding likely to be more complex and vast post ICD-10, the scope for coding may be even more.

There could have been considerable in claim submission, so much so that insurance payers could reject them on grounds of being too late to be accepted.

Lack of denial management too may have been another reason; it takes special expertise to track and follow up denials in a system characterized by multiple payers

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It really takes an effective system to monitor and compare underpayments against contracted fee schedules, be it is Medicare, Medicaid or popular commercial health plans. The reasons for underpayments such as the ones highlighted can only be unearthed through a careful analysis of Revenue Cycle Management processes employed by orthopedic surgeons.

Medicalbillersandcoders.com – which has been a resource center for comprehensive medical billing solutions – can mediate the deployment of resources (orthopedic billing specialists) that offer remedial solutions to underpayment issue plaguing the orthopedic surgeons. Significant of advantage of sourcing resources through our platform is that you will get discover the real reason for a decrease in revenue; problems that should be addressed such as credentialing, insurance verification/precertification, collections, coding, and payer mix; and recognize the reasons for denials and comparing payments to the fee schedule to resolve issues with payers.

Orthopedic Billing Specialist to Take Care of CPT Code Changes Made to Orthopedic Surgery Billing in 2013

This year’s CPT Manual has spelt out extensive coding changes and revisions to orthopedic surgical codes.  In all, there are 500 code changes to the Category I codes, including 251 revisions, 151 new codes and 100 deletions. Moreover, there has been significant overhauling of nerve conduction studies, some revisions to the radiology section, and E/M changes. The extent of these coding changes and revisions, having already taken effect from January 1, 2013, has begun to impact orthopedic reimbursements in a big way. As a result, orthopedic practices may have inherited an ominous task of migrating to   a higher order in orthopedic surgical coding. Given the CPT Manual’s full list of revisions, deletions, and additions to have been effected for 2013, orthopedic practices would require to be conversant with the guidelines for the following coding sections:

Spine CPT Errata, whereinchange has been added to the spine bone grafts (20930–20938), instrumentation (22840–22844, 22848, 22845–22847), and intervertebral device (22851) CPT codes.

Bone marrow aspirate, wherein explanation has been added to bone graft codes (20930–20938) related to bone marrow aspiration. Henceforth, Category III code 0232T should be used when bone marrow aspiration is performed for platelet-rich stem cell.

Cervical Spinal Arthrodesis, which is now required to be coded as per the new guidelines issued to CPT codes 22554, 22585, 63075, and 63076

Cast application, which now includesguideline changes made to “Application and Strapping” section addressing the application of the first cast, its removal, coding by the individual who performs the initial service, and restorative management.

Hip arthroscopy, under whichCPT code 29916 (Arthroscopic labral repair of a torn labrum) is now considered inherent to CPT codes 29915, 29862, and 29863.

Chemodenervation, in which a new guideline change is introduced for CPT code 64614 used in  Chemodenervation of muscle(s); extremity and/or trunk muscle(s)

Intraoperative nerve monitoring is now included in the primary surgical service and is not separately reportable.

New CPT codes applicable to procedures for spine, shoulder arthroplasty, elbow arthroplasty, nerve conduction, extracorporeal shock wave: wound healing, etc.

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While these are some of the notable changes and guidelines to have been effected for orthopedic surgical coding since the beginning of 2013, orthopedic practices may need to follow these action steps to be fully compliant with the changes and revisions:

• Analyze the 2013 CPT Manual in its entirety to understand the guideline changes found throughout it. Specifically focus on the E&M changes and new codes that may have applicability to your practice.
  
  
• Revise charge capture tools, electronic health record (EHR) lists and short lists or favorites, if charge capture is performed within the EHR.
  
  
• Enroll with an accredited orthopedic surgical coding course.

Medicalbillersandcoders.com – which has always stood by the physician community during times of medical billing and coding crisis – has arranged for networking with the right resources (orthopedic coding specialists) to maneuver through this major surgical orthopedic coding changes and revisions. The competence and experience of our select pool of surgical Orthopedic Billing specialists should help you minimize the impact of this coding change and revision while ensuring appreciable increase in orthopedic reimbursements.