The document outlines essential strategies for avoiding claim denials in orthopedic billing, emphasizing the importance of accurate coding and insurance verification. It highlights common causes of denials, such as incorrect demographics and improper use of codes and modifiers, and suggests automation or outsourcing to specialized billing professionals. Implementing these practices can significantly enhance reimbursement processes and reduce the occurrence of claim denials.

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Avoid Denials For Your Orthopedics Billing
Getting paid by insurance timely and accurately in any medical specialty including orthopedics is a vigorous
process. The introduction of new billing and coding rules is a regular part of 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 imply a loss in reimbursements after all the wait. Hence, it is
imperative that orthopedics billing and coding are 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.

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Avoid Denials For Your Orthopedics Billing
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 the 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:

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Avoid Denials For Your Orthopedics Billing
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, 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 Payers For Orthopedic Billing Which Must Be Checked For Include:

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Avoid Denials For Your Orthopedics Billing
 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.
Medical Billers and Coders (MBC) is a leading outsourcing medical billing company providing
complete revenue cycle services. To know more about our orthopedics billing and coding services, contact us
at info@medicalbillersandcoders.com/888-357-3226.