The Centers for Medicare & Medicaid Services (CMS) has clearly set policies and reimbursement rates for providers and follows the Physician Fee Schedule guidelines to streamline the billing process. Medical billing and coding for orthopedic surgeries have very similar guidelines. However, the global pandemic has had adverse effects on the medical billing reimbursements for orthopedic surgeries.

For instance, consider that the federal COVID-19 relief packages could have a significant impact on the additional cuts, while leaving lower margins for small practices and physicians. While reimbursement cuts are inevitable in the current scenario, one of the major concerns is that these cuts should not limit patient access to care at the time when they need it the most.

There has been a paradigm shift in the coding and billing policies for providers including the reimbursements for orthopedic surgeries. CMS has announced various policies in 2021 under Medicare Physician Fee Schedule (MPFS) to reduce orthopedic surgical services by at least 5%. This is bound to add to the financial burdens of orthopedic hospitals and practices that are already adversely affected by the financial impact of the public health emergency.

This article focuses on the top reasons for claim denials in orthopedic billing and gamechanging strategies to improve orthopedic surgery reimbursements

Common Causes for Denials in Orthopedic Coding

Key Categories of Claim Denials in Orthopedic Billing

Three types of denials constitute orthopedic billing.

Clinical Denials

• Denials pertaining to medical necessity
• Length of hospital stay post-surgery
• Follow up visits processes that are not followed

Administrative Denials

• Incorrect or missing details
• Invalid or incorrect codes
• Services uncovered by the insurer
• Bundled services
• Itemized bills

Omission Denials

• Incorrect documentation of prior authorization
• Incorrect patient details or registration
• Have not met the eligibility verification criteria

5-Point Checklist to Prevent Claim Denials in Orthopedic Billing

1. It is critical that the medical billing and coding team stays on top of the latest codes announced by the American Medical Association (AMA). These has been 279 new ICD codes, 143 revised codes and over 50 codes that have been removed. The orthopedic billing and coding services team needs to ensure that all the latest coding changes have been updated.
2. The medical billing and coding team must stay current on the investments involved in updated coding.
3. Understand the most common reasons for denials and leverage analytics and automation strategies to prevent future denials. Duplicate claims and claims that exceed the fee schedules are amongst the top reasons for orthopedic claim denials.
4. Collect accurate patient details as inaccurate or inadequate documentation could cause confusion while submitting claims. An automated billing software helps mitigate errors and improves billing accuracies.
5. Specificity of the injury and the surgery is essential in terms of orthopedic care. It is critical that the physicians diagnose the specific area of disease and document accurate details before claim submission.

Also Read:

2021 OPPS Final Rule: Key Takeaways from the CMS Policy

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Medicare Physician Fee Schedule: CMS Update

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CMS Proposes to Permanently Expand Telehealth Service Benefits

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CMS Interoperability and Patient Access Final Rule

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Top Tactics to get Upfront Healthcare Reimbursements during COVID-19: CMS Accelerated and Advance Payment Program

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$2T Stimulus: Restructuring Healthcare Ecosystem

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To learn more about how your healthcare organization can prevent orthopedic denials and improve denial management services, talk to our team.