Accurate coding and billing are essential to getting reimbursed for proper reimbursement of orthopedic services. Errors in claim submission can lead to denials and even substantial fines. However, billing and coding for this specialty present unique challenges due to the complexity of orthopedic insurance verification and prior authorization, procedures, frequent use of modifiers, and evolving payer guidelines.
Partnering with an orthopedic medical coding company helps practices streamline revenue cycle management (RCM), enhance claim accuracy, and reduce denials. Experts use a specialized billing and coding cheat sheet to ensure precise and efficient claim submissions. This blog highlights common billing challenges faced by orthopedic practices and how using this cheat sheet can optimize revenue cycle management (RCM).
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Common Challenges in Orthopedic RCM
Orthopedic practices face high denial rates due to missing documentation, incorrect coding, and non-covered services. Here are some key factors that contribute to the complexity of orthopaedic RCM:
- Complex coding for diverse procedures: Orthopedic procedures, such as joint replacements, fracture treatments, and arthroscopic surgeries require precise CPT, ICD-10, and HCPCS coding. CPT codes vary based on whether the treatment is open, closed, or percutaneous, leading to potential coding errors.
- Frequent use of modifiers: Correct use of modifiers (-50, -59, -RT, -LT) is essential to avoid claim denials.
- Challenges of insurance verification: Orthopedic treatments often require prior authorization and strict medical necessity documentation.
- Global periods: Understanding and tracking global surgery periods is critical for proper billing of follow-up care.
- Bundling and unbundling issues: Incorrect bundling or unbundling of procedures can lead to underpayment or audits.
- Workers’ Compensation and personal injury claims: These claims require special handling, extended processing times, and additional documentation.
- Durable Medical Equipment (DME) billing: Coding and reimbursement for braces, splints, and prosthetics follow specific payer guidelines. Incorrect HCPCS coding or lack of documentation can lead to non-payment.
Let’s dive into what an orthopedic billing cheat sheet include and how it ensures adherence to best practices for accurate reimbursement.
Key Elements of a Cheat Sheet for Orthopedic Billing and Coding
An orthopedic billing and coding cheat sheet is a valuable resource that provides quick access to essential codes, modifiers, and billing guidelines for orthopedic procedures. It improves accuracy, maintains compliance, and minimizes audit risks and financial penalties. The key elements of this cheat sheet are as follows:
- Common Orthopedic Procedures and Their Codes
The cheat sheet includes commonly performed orthopedic treatments and their corresponding procedure codes, allowing medical coders and billers to quickly reference and select the correct codes for efficient and accurate billing. Here are some examples of CPT and ICD-10 codes for orthopedic procedures —
CPT Codes
Fracture Care & Trauma
21310 – Closed treatment of nasal bone fracture without manipulation
23500 – Closed treatment of clavicular fracture; without manipulation
23515 – Open treatment of clavicular fracture, with or without internal or external fixation
28505 – Open treatment of fracture great toe, phalanx or phalanges, includes internal fixation, when performed
Arthrocentesis, aspiration, injection
20600-20611
Arthroscopic Procedures
29881 – Arthroscopy, knee, surgical, with meniscectomy (medial or lateral)
29877 – Arthroscopy, knee, with debridement/shaving of articular cartilage
29826 – Arthroscopy, shoulder, with subacromial decompression
Joint Replacement & Reconstruction
27130, 27134, 27137, 27138 – Total hip replacement
27446, 27447, 27487 –Total knee replacement
23470, 23472, 23616 – Total shoulder replacement
Tendon and Ligament Repair
24341 – Repair of ruptured biceps tendon
25260 – Repair of flexor tendon in the hand
27650 – Repair of Achilles tendon
Spine Procedures
22551 – Anterior cervical discectomy and fusion (ACDF)
22612 – Lumbar spinal fusion
Other Common Orthopedic Procedures
20550 – Injection(s), single tendon sheath (e.g., for tendonitis)
27310 – Biopsy of muscle
64721 – Neuroplasty and/or transposition; median nerve at carpal tunnel
Durable Medical Equipment (DME)
HCPCS Level II codes commonly used for DME:
L1833 – Knee orthosis, adjustable knee joints (e.g., post-op knee brace)
L0650 – Lumbar-sacral orthosis (LSO) for back support
L3908 – Wrist-hand orthosis (e.g., for carpal tunnel syndrome)
Workers’ Compensation Cases
99204-99205 – New patient evaluation and management (E/M) for detailed injury assessment
99213-99215 – Established patient visits for ongoing injury management
97010 – Application of hot or cold packs for injury treatment
97110 – Therapeutic exercises to restore strength and mobility
ICD-10 Codes
Using the appropriate ICD-10 codes supports comprehensive and accurate diagnosis. Here are some common ICD-10 codes in orthopaedics:
S42.001A – Fracture of unspecified part of right clavicle, initial encounter
S52.501A – Unspecified fracture of the lower end of right radius, initial encounter
M17.11 – Unilateral primary osteoarthritis, right knee
M75.100 – Unspecified rotator cuff tear or rupture of the right shoulder
S46.011A – Strain of right rotator cuff, initial encounter
S86.011A – Strain of right Achilles tendon, initial encounter
M54.5 – Low back pain
M47.812 – Spondylosis without myelopathy or radiculopathy, cervical region
Z47.1 – Aftercare following joint replacement surgery
Z96.641 – Presence of right knee replacement
Z96.711 – Presence of right hip implant
- Modifiers
Modifiers are essential in orthopedic medical billing and coding, providing additional details that ensure accurate claim processing and reimbursement. These two-character codes clarify how a procedure or service should be reported, enhancing precision in medical records. Proper use of modifiers prevents claim denials by offering necessary context. Here are some common modifiers used in orthopedic billing:
- 50 (Bilateral procedure) Indicates that a procedure was performed bilaterally
- 51 (Multiple procedures) Indicates that multiple procedures were performed during the same session.
- 59 Distinguishes procedures or services that are typically not reported together but are suitable under specific circumstances.
- LT Indicates that a service or procedure was performed on the left side of the body
- RT Indicates that a service or procedure was performed on the right side of the body
- Level II HCPCS modifiers add specificity to a HCPCS code
Use of orthopedic billing modifiers can vary depending on the specific procedure and the payer’s requirements. Best practices for modifier use in orthopedic billing
- Maintain Accurate Documentation
- Select the Correct Modifier
- Adhere to Payer Guidelines
- Monitor Reimbursement Trends
- Understand Bundling Rules
- Justify Medical Necessity
- Bundling
A bundling package defines which surgical CPT codes can be reimbursed either separately or in combination. Here’s an example from the American Orthopaedic Association:
CPT code 29880 denotes both a medial AND lateral meniscectomy. The following procedures are bundled with this code and cannot be billed separately:
29881 – medial OR lateral meniscectomy: is obviously included with medial AND lateral.
28982 – medial OR lateral meniscal repair: cannot be reimbursed when you have performed a meniscectomy
28983 – medial AND lateral meniscal repair: cannot be reimbursed when you have performed a meniscectomy
Unbundling occurs when separate CPT codes are billed for individual components of a procedure instead of using a single comprehensive code. This common billing error often leads to claim denials and audit issues. Conversely, incorrect bundling can result in underpayment, impacting reimbursement. Proper coding ensures accurate claims and optimal reimbursement.
- Global Periods
Global periods define the timeframe during which preoperative and postoperative care are included in a single payment and cannot be billed separately. For example, in orthopedic medical billing, a total knee replacement (CPT 27447) has a 90-day global period, meaning all routine follow-up visits, wound care, and post-surgical evaluations within those 90 days are covered under the initial surgical fee. Billing separately for these services could result in claim denials or compliance issues. Proper tracking of global periods helps ensure accurate reimbursement and prevents billing errors.
- Orthopedic Billing Requirements
Billing requirements for orthopedic procedures ensure compliance with payer guidelines and enable accurate, timely reimbursement. Documentation guidelines specify the necessary information to support billed services, while medical necessity criteria justify procedures based on the patient’s condition. Special considerations may include pre-authorization, specific coding rules, or coverage limitations. Adhering to these requirements is crucial for orthopedic practices to effectively navigate the reimbursement process.
- Compliance Guidance
Compliance guidelines offer clear, up-to-date direction on HIPAA regulations, accurate and ethical coding, proper modifier use, global period rules, medical necessity, payer-specific requirements, and NCCI edits. Adhering to these guidelines helps providers ensure lawful and ethical billing, reduce claim denials, and maintain a high standard of care.
Using the Cheat Sheet
For effective use of the orthopedic billing and coding cheat sheet:
- Ensure clear and comprehensive documentation
- Have a clear understanding of CPT, ICD-10 and HCPCS codes and modifier use
- Align ICD-10 and CPT codes for various condition
- Adhere to payer guidelines
- Conduct regular coding audits to identify billing trends and errors to refine processes and avoid repeat denials.
- Analyze trends in coding errors, missing documentation, and authorization issues.
- Use a denial tracking system to classify denials by type (e.g., medical necessity, bundling, modifier errors)
- Submit appeals with supporting documentation to overturn incorrect denials
An orthopedic medical billing and coding company will regularly update the cheat sheet to reflect the medical code changes, modifier rules, payer guidelines, and compliance updates. Keeping the cheat sheet current ensures accurate claim submissions, reduced denials, and optimized revenue cycle management for orthopedic practices.
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