A must-have for insurance reimbursement, medical coding has been around for over fifty years and has only grown in importance. It’s the way orthopedists define and justify a patient’s level of service and the severity of their diagnosis for billing purposes. Whether in a hospital or practice setting, ICD-10-CM and CPT coding are of paramount importance to maximizing insurance reimbursement and avoiding claim denials and rejections.

Orthopedics coding, with all of its intricacies, can impact revenue and bottom-line results in a significant way. Like many practices, your current revenue cycle management (RCM) model may rely on in-house medical coding, but this may not be adequate. By engaging a third-party coding partner, your orthopedics practice could jumpstart the process of improving your coding program in the future.

Support Provided by an Orthopedics Medical Coding Team

An experienced third-party medical coding partner’s invaluable benefit brings to a practice is undoubtedly a fresh pair of eyes. In the day-to-day business of RCM, it’s easy to become singular in focus. An objective third-party team can audit the processes being used and to recommend, train, and help implement changes that positively transfer directly to your bottom line.

During the medical claims adjudication process, insurers decide if the diagnosis and treatment match (as defined by the CPT and ICD-10 codes selected) with the community’s standard of care and are appropriate for the injury or disease being treated. If there is a discrepancy, the claim is denied or rejected and, if not followed-up on, the revenue is lost completely.

A recent report by the Medical Group Management Association (MGMA), estimated that between 50-65% of denied claims are abandoned with no rework, resubmission, or follow-up. This runs contrary to every practice’s goal to maximize reimbursement and collect revenue in the shortest amount of time possible.

The Challenge of Orthopedic Coding Complexities

Understanding coding complexities can be an overwhelming task and one that has long-reaching consequences. Not only are coding results monitored by insurance payers, but there can be serious legal and financial consequences if miscoding continues once identified.

Here we outline some of the complexities that orthopedic practices encounter:

  • Correct Code Selected – Was the right CPT code selected for the services performed (including any associated procedures and/or tests), and was it assigned the proper ICD-10 diagnosis code?
  • Level of Specificity – ICD-10 codes should be hyper-specific to the diagnosis and must be coded to the highest level.
  • Correct Order – When using multiple codes to define a diagnosis, always use the specific reason for a patient’s visit first and then follow codes that further describe detail.
  • Unbundled Charges – Charges for procedures or tests that are represented separately when they should be part of a designated diagnosis bundle will cause a claim to be rejected.
  • Upcoding or Downcoding – Codes should be for the exact level of service performed, and there can be significant consequences if a practice continually either up or down codes their visits.
  • Appropriate Modifiers – The use of appropriate modifiers for CPT and HCPCS codes is critical for proper reimbursement.
  • Documentation – Every visit or patient encounter should be documented adequately within the patient’s health record. This provides information on a claim-by-claim basis if requested for reimbursement. It also supports any request for payment should the practice be audited by an insurance provider or governmental agency.

The Benefits of Using a Third-Party Coding Partner

Orthopedics practices are busy — their day-to-day care schedules and RCM clip along at a fast pace. An important function like medical coding should be subject to frequent internal audits and quality control. Further, adequate time needs to be devoted to keeping up with the latest updates and regulatory changes.

By engaging an experienced third-party orthopedics medical coding partner, you can expect:

  • Better reimbursement and greater efficiency brought by a thorough knowledge of orthopedic coding, both inpatient and ambulatory or practice related.
  • A comprehensive understanding of the insurance payer market in your area and
    contracting requirements specific to your specialty and practice.
  • Strong communication regarding data analytics and process improvements—know where you stand financially.
  • Ongoing training and education for providers and business office personnel with timely deadlines for documentation and claims adjudication.
  • A robust compliance and ongoing quality improvement program that incorporates changes and updates as they become effective.

With the new 2021 coding changes taking effect soon, now is a perfect time to consider moving your coding functions to a third-party partner. You can alleviate the need for additional education and hit the ground running with experts in their field. This allows you to “not skip a beat” and, in fact, potentially increase your bottom line with better collections and reduced denials.

Find out more today by contacting us to discuss how to facilitate a strong medical coding program for your orthopedics practice.