Currently, nearly 23% of adults older than 40 have knee osteoarthritis.

As the American population ages and gains weight, the demand for osteoarthritis therapy viscosupplementation has risen rapidly. Market forecasters report that the viscosupplementation market size is on track to grow by 9.45% every year for the next five years. To put it in dollars and cents, osteopaths and hospitals billed $4.52 billion in viscosupplementation in 2021. By 2026, they’ll be billing $7.08 billion for the hyaluronic gel injections.

While potential increased revenue promises to swell orthopedists’ cash flow, a common stumbling block persists: claims denials.

Here, we cover how you can reduce your viscosupplementation denials significantly.

Common Payer Reasons For Issuing Viscosupplementation Claims Denials

The majority of denials arise from mistakes and missed deadlines on the provider’s end. Make sure your staff is on top of the most common reasons for denials so they can avoid them.
Payers deny due to:

  • Failure to obtain prior authorization or meet the plan criteria in a way sufficient to show medical necessity.
  • Using the incorrect diagnosis. The only covered diagnosis is osteoarthritis.
  • Insufficient documentation to support medical necessity.
  • Missed deadlines – anything from incorrect insurance information which leads to a back-and-forth between payer and provider or delays in claim submission can lead to denials.

Current Tactics For Reducing Viscosupplementation Claims Denials

We have observed that more than half of all denials (not just viscosupplementation denials) are caused by patient access issues — eligibility, prior authorization insufficiencies, and services not being covered.

Unfortunately, with a crushing workload, staff today struggles to get claims submitted accurately and on-time. Between staffing shortages and attrition, staff is overwhelmed.

Still, best practices for avoiding claims denials spell out that claims specialists should:

  • Verify the patient’s policy to confirm the policy is active at the time of service.
  • Verify that the injection is covered by the patient’s benefit plan.
  • Ensure all the information is accurate — such as patient’s info, place of service, billing provider, etc.
  • Perform the injection within the time frame approved by the patient’s insurance company (if a time frame is provided). Some insurance companies will approve the visco injection(s) and allow for it to be performed within 2 weeks or up to 6 months.
  • Know the appropriate codes to report. If it is the patient’s first time being treated and evaluated you may submit an E/M along with the procedure (injection) codes.
    • Ensure appropriate modifiers are attached
    • Select diagnosis codes to the highest level of specificity

Real-Life Use Cases On Coding Correctly To Avoid Denials

Consider these two scenarios:
Scenario One: Patient comes into the office for a new problem/injury. The physician evaluates, diagnoses, and establishes a course of treatment for injection(s). The physician decides to perform the injection at the time of the visit.
Assuming the clinical documentation is supported, both an E/M and injection can be billed with modifier 25 on the E/M.

CPT Code Modifier Diagnosis
99213 25 M17.11
20610 RT M17.11
J7324 N/A M17.11

 

Scenario Two: The patient returns to the office a week later to continue the treatment plan (as recommended by the provider) for the injection series. There has been no change in the patient’s progress, and the provider does not perform a physical exam.
A separate E/M is NOT appropriate to bill along with the injection.

CPT Code Modifier Diagnosis
20611 N/A M17.0
J7324 RT M17.11

 

Artificial Intelligence And Automation Can Help Keep Viscosupplementation Denial Rates Down

Nearly all of the errors committed by providers that prompt payer denials can be reduced with the help of artificial intelligence and automation technology at the front office patient access and back office revenue cycle workflows.

Such technology assists providers in coding correctly the first time, reducing denials down the line. Because it provides a reliable database of continually updated prior authorization requirements for hundreds of payers, prior authorization requests become less burdensome and staff is more likely to file them on time.

In the current payer-favored legislative climate, having such technology supporting your orthopedics team optimizes revenue collection and keeps your department or practice viable.

Plus, it’s not just an aging, weight-gaining population fueling viscosupplementation demand. Today’s patients prefer minimally invasive procedures over surgical ones. Awareness that a hyaluronic acid solution alleviates pain and gets them active again is spreading.

Orthopedics departments and providers can get and keep more of their revenue by leveraging AI-driven revenue recovery software. We have seen a 40% reduction in denial rates and 64% in denial & aging A/R write-offs. .

Schedule a demo to see how our solution drops denial rates and lifts the burden of denials management from your staff.