Streamlining Orthopedic Billing in 2024 February 15, 2024

Orthopedic medical billing is a constant challenge for many practices in the U.S. due to changing regulations and regular updates in billing codes. The billing process requires a high level of accuracy, but with thousands of codes, several modifiers, and insurance information, discrepancies tend to occur more often than expected.

Significant repercussions can result from billing errors, such as financial losses, non-compliance issues, and harm to the practice’s reputation. One healthcare provider was fined $400,000 and permanently excluded from participating in Medicare and Medicaid due to upcoding. They billed for 30- or 60-minute face-to-face sessions with patients when they only met with them for 15 minutes each to do medication checks. 

To help clinics navigate the coding landscape and mitigate these risks, we’ve compiled a comprehensive orthopedic billing guideline that covers critical updates, common challenges, best practices, and innovative solutions.

Orthopedic Billing Guidelines for 2024

Medical billing and coding substantially impact the orthopedic clinic’s revenue cycle. Both are essential for ensuring that orthopedic practices receive timely and accurate payment. 

Staying up to date with recent coding changes is critical to mastering these financial components. Some significant changes included the impacts of COVID-19, the No Surprises Act Provision, and the introduction of new billable codes.

COVID-19 Pandemic

In 2020, the healthcare industry saw a 2.3 percentage point increase in adopting electronic claims management in medical and dental fields. The COVID-19 pandemic prompted increased transactions, including but not limited to verifying eligibility and benefits, obtaining prior authorization, submitting claims, checking the status of claims, making claim payments, and receiving remittance advice.

The No Surprises Act Provision

This federal law aims to safeguard patients from unforeseen medical bills, especially in cases that involve out-of-network healthcare providers. The No Surprises Act law, passed as part of the Consolidated Appropriations Act in 2021, introduces several measures to increase transparency, restrict patient financial liability, and establish equitable dispute resolution processes between insurers and providers. 

New Billable Codes in 2024

Medical coders use the following specialized coding classification systems to create standardized codes that correspond to a physician’s diagnosis, procedure, drug, or other services. 

• Current Procedural Terminology (CPT)
• International Classification of Diseases (ICD)
• Healthcare Common Procedure Coding System (HCPCS)

In the fiscal year 2024, the ICD-10-CM code system introduced 395 new billable codes covering various areas such as external causes of morbidity, social determinants of health, and osteoporosis. These 2024 coding updates will help healthcare providers have a more accurate and comprehensive understanding of patient health conditions.

Common Challenges in Orthopedic Billing

Medical coding is subject to regular updates and revisions. Failing to stay informed can lead to the use of outdated codes, which will result in claim denials and payment delays. 

Other possible billing errors that may arise in your organization include: 

1. Complex Coding for Procedures

Orthopedic procedures often involve a range of surgical and diagnostic codes. Due to their complexity, coding errors may occur, resulting in incorrect billing and potential claim denials. 

2. Upcoding or Downcoding 

Upcoding (billing for a more expensive service than performed) and downcoding (billing for a less costly service) can have severe consequences. Upcoding may lead to fraud and legal action accusations, while downcoding may result in lost revenue. 

3. Implant and Device Coding

Orthopedic procedures frequently involve the use of implants and devices. Billing for these items can be challenging, as different payers may have specific requirements for reporting these costs. 

4. Failure to Verify Insurance Coverage

Neglecting to verify patients’ insurance coverage before providing services can lead to claim denials and delays. Patients may have changes in their coverage, such as policy lapses or deductible adjustments, which can affect billing accuracy. 

5. Global Surgical Package Compliance 

Orthopedic surgeries often have a global package of pre-operative, intra-operative, and post-operative services. Billing errors can happen if the billers fail to bundle all the services that are part of the global package or bill separate services incorrectly. 

6. Documentation of Medical Necessity

Demonstrating medical necessity for procedures is crucial for successful billing in orthopedics. Insufficient documentation of the necessity for surgeries, imaging, or other interventions may result in claim denials or delays in payment. 

7. Correct Application of Modifiers

Orthopedic billers use modifiers to specify particular circumstances or conditions associated with a service. However, incorrect modifiers, especially those related to multiple, bilateral, or co-surgery procedures, can result in coding mistakes and payment discrepancies.

Best Ways to Stay on Top of Orthopedic Billing Changes

Orthopedic billers and coders can follow these best practices to keep up with various billing changes:

Complex Coding

Given the intricacies of orthopedic surgeries and interventions, coders must deeply understand the specific orthopedic billing codes associated with each procedure. Comprehensive coding knowledge ensures that claims involving joint replacements, spinal surgeries, or diagnostic interventions are filed correctly.

Upcoding or Downcoding

Accurate representation of the complexity and intensity of orthopedic services is a fundamental best practice in billing. Orthopedic practices must maintain integrity in their billing processes by avoiding upcoding and downcoding. 

Verify Insurance Coverage

Confirming coverage details, including policy changes or deductible adjustments, can help orthopedic practices minimize the risks of incorrect billing or claim delays.

Global Surgical Package Compliance 

Orthopedic practices must adhere to global surgical package guidelines, bundling services properly and avoiding unbundling errors. This ensures that claims reflect the entire scope of care provided during the global period (either 10 or 90 days after the procedure). 

Correct Modifiers

Orthopedic procedures often require modifiers to convey specific circumstances or conditions related to a service. Careful application of these modifiers helps prevent coding errors and ensures that the billed amount accurately reflects the complexity of the provided services. 

In addition to best practices, orthopedic coders and billers can use these strategies to reduce errors and delays: 

1. Use of Automated Systems

Utilizing electronic health records (EHR), orthopedics medical billing software, and revenue cycle management (RCM) systems can streamline workflows. These automated systems can help catch coding errors, ensure regulation compliance, and facilitate quicker claims processing. 

3. Consider Outsourcing

Some orthopedic practices outsource their billing processes to specialized medical billing companies. Outsourcing can provide access to experts with specific knowledge in orthopedic billing, reducing the burden on in-house staff and mitigating the risk of errors.

2. Ongoing Training

Continuous training for billing and coding staff is essential to update them on the latest coding and orthopedic billing guidelines, documentation requirements, and procedural updates. Training programs may also focus on communication between clinical and billing teams to enhance efficiency.

Our Solutions For Orthopedic Billing

Specialized billing applications can benefit orthopedic practices looking to improve their processes. This software can help streamline the billing process and significantly reduce errors. 

At 5 Star Billing Services, we have a team of experienced billers and coders skilled in utilizing a variety of billing software programs such as:

• 1st Providers Choice
• Allscripts
• ChiroTouch
• eClinicalWorks
• Greenway Prime Suite
• HST Pathways
• IMS – Intelligent Medical Software

Our team can assist orthopedic practices in selecting the best orthopedic billing software system for their needs. We have the expertise to handle complex billing codes, interpret office and operative notes, and are well-versed in coding for surgical procedures.

Takeaway

By prioritizing accurate coding, insurance verification, and global surgical package compliance, orthopedic billers can mitigate risks of financial losses and compliance issues. Leveraging technology, staff training, and outsourcing orthopedic billing services can create a robust strategy for reducing errors and navigating the healthcare billing landscape with resilience.

Tap Into Our Expertise

At 5 Star Billing Services, we offer unparalleled expertise in medical billing services to meet your unique needs. Our team of specialists has been providing top-notch assistance since 2007. We have helped clients across the United States utilize diverse billing software and stay up-to-date with evolving regulations. 

We invite you to book an appointment and experience our proficiency in elevating your billing experience.