How to Properly Bill for Orthopedic Medical Billing Services Step-by-Step Guide

Being a good orthopedic practitioner and treating several patients are not the only things you must practice. 

Medical billing and coding is a specialty that every practitioner should be aware of. 

In the complex world of healthcare, accurate billing is crucial for ensuring that orthopedic services are compensated appropriately. 

Whether you are a seasoned healthcare practitioner or new to the field, understanding how to navigate orthopedic medical billing can help you avoid costly mistakes and ensure your practice runs smoothly. 

In this guide, we will walk you through the essential steps for effective orthopedic medical billing, helping you streamline your processes and improve your revenue cycle.

What is orthopedic medical billing?

Orthopedic medical billing refers to the process of submitting claims for services provided by orthopedic specialists, including surgeries, consultations, and diagnostic tests. This specific area of billing requires a thorough understanding of medical codes and regulations related to orthopedic practices. By utilizing the correct codes and following billing guidelines, healthcare providers can ensure they receive timely reimbursement for their services. Without accurate orthopedic medical billing and coding, physicians and surgeons may not receive insurance payments, potentially leading to financial strain for those who rely on these payments to sustain their practices. Additionally, proper billing ensures that patients receive appropriate care aligned with their diagnosis codes.

How to bill for orthopedic visits?

Medical billing requires several steps to ensure accuracy and timely reimbursement, Orthopedic visit is not an exception. 

It all starts with gathering complete patient information, including demographics, insurance, and medical history. During the visit, thoroughly document the patient’s complaints, examination findings, diagnoses, and treatment plan. Once the visit is documented, select the appropriate Current Procedural Terminology (CPT) codes.

The only thing that differs is the Evaluation and Management (E/M) codes. 

For office visits, use an E/M code from 99201-99205 for new patients, and for established patients, use 99211-99215, based on the complexity of the visit. 

Submit claims to the patient’s insurer, ensuring all necessary documentation is included to support the billing. Finally, follow up on the claim status and promptly address any denials or issues to facilitate payment and reduce disruptions. Accurate and complete billing is crucial for maintaining the financial health of orthopedic practices.

Common Orthopedic Procedure Codes Explained

Familiarity with common orthopedic procedure codes is vital for effective billing. It helps simplify the billing process by providing quick access to codes for procedures like knee arthroscopy, joint replacements, and fracture care. This allows healthcare professionals to accurately document services, making the reimbursement process smoother and ensuring claims reflect the care provided.

CPT codes are specific codes used to describe medical and surgical services. Using CPT codes correctly is important for documenting services accurately and making billing easier. Here’s a list of common orthopedic procedures along with their corresponding CPT codes for easy reference:

• Arthrocentesis (Aspiration, Injection): 20600-20611
• Total Hip Arthroplasty: 27130
• Total Knee Arthroplasty: 27447
• Closed Treatment of Fracture: 28515
• Open Treatment of Fracture: 11010-11012
• Repair of Rotator Cuff: 23410
• Repair of ACL: 29888
• Carpal Tunnel Release: 64721
• Spinal Fusion: 22554

Billing for Orthotic Repairs and Devices

Orthotic devices, such as braces, splints, and prosthetics, are critical to patient care, helping improve mobility, prevent further injury, and enhance the quality of life. When these devices need repairs or replacements, proper billing becomes essential for healthcare providers to ensure they receive accurate reimbursements while maintaining compliance with payer regulations. 

Here’s a quick guide:

• Physician’s Prescription

Ensure a valid prescription for the repair or new orthotic device is in place.

• Use Correct HCPCS Codes

Healthcare Common Procedure Coding System (HCPCS) codes are essential for billing orthotic devices. 

When billing for repairs or replacements, make sure to:

Use appropriate HCPCS codes that represent the orthotic device or the service provided.

For repairs, include detailed HCPCS codes specific to the type of repair needed (e.g., joint adjustments or padding replacements).

For example:

L4205: Repair of orthotic device, labour component, per 15 minutes.

L4210: Repair or replacement of minor parts, such as screws or straps.

These codes help payers understand the extent of the repairs and the materials or parts used.

• Apply Modifiers

Modifiers are crucial in DME billing as they help convey specific information to the payer. 

Common modifiers used for orthotic repairs include:

• NU (New Equipment): For billing a new orthotic device.
• RR (Rental): If the orthotic is rented.
• RP (Repair and Replacement): Used when billing for the repair of an orthotic device.

Ensure you are familiar with payer-specific modifier requirements, as incorrect modifier usage can lead to claim denials.

• Submit Documentation

Provide a detailed description of repairs, factory invoices, and a signed Certificate of Medical Necessity (CMN) when needed.

• CMS-1500 Form

Submit claims using the CMS-1500 form, ensuring accuracy and completeness.

• Medicare Coverage

Medicare covers repairs deemed medically necessary but not luxury upgrades or repairs exceeding the cost of a new device.

Ensuring Accurate Billing for Orthopedic Surgeries

Accurate billing for orthopedic surgeries is crucial to maintaining compliance, maximizing reimbursements, and avoiding costly claim denials. Here’s a comprehensive guide to ensure your billing is done correctly and efficiently.

1.Verifying Patient Coverage (pre-authorizations)

Before any surgery takes place, start by verifying the patient’s insurance eligibility. This step acts as the foundation of a smooth billing process. Verifying coverage in advance and obtaining any necessary pre-authorizations prevents surprises in the form of denials or reduced payments later. Insurance coverage details are essential to ensuring the procedure will be reimbursed.

2. Using Correct CPT Codes in Orthopedic Medical Billing

Accurate coding is the backbone of successful orthopedic Medical billing. Every surgical procedure has a specific CPT code that reflects the complexity of the surgery:

• CPT 27447: For total knee replacements.
• CPT 25607: For open treatment of fractures of the radius.

Selecting the correct code based on the procedure performed ensures accurate billing. Incorrect coding may lead to denials or delays in reimbursement, making code precision critical.

3. Applying Modifiers to Avoid Bundling Errors

Modifiers are used to clarify specific circumstances of a procedure, ensuring that services are billed correctly:

• Modifier -51: Applied when multiple procedures are performed during the same surgical session (e.g., multiple joint repairs). It shows the payer that while these services are related, they are distinct.
• Modifier -59: Used when two distinct services are provided during the same session but are not typically bundled together (e.g., surgery on different body parts).

Using modifiers correctly helps avoid claim bundling issues, preventing revenue loss from denied claims.

4. Postoperative Care and the Global Surgical Package

Most orthopedic surgeries fall under a global surgical package, which includes the preoperative visit, the surgery itself, and postoperative care (usually within 90 days). 

To ensure accurate billing:

• Do not bill separately for services covered under the global package, such as routine post-op visits.
• Keep track of services that occur outside the global period, such as treatment for complications, as these can be billed separately.

Being mindful of the global period guidelines ensures compliance and avoids overbilling, while also capturing revenue from services outside of this period.

5. Proper Use of Documentation

Comprehensive documentation is essential in supporting claims for orthopedic surgeries. Detailed records of the procedures performed, the medical necessity for the surgery, and any complications encountered ensure that the billing aligns with the care provided. Thorough documentation helps avoid misunderstandings during claim review and supports accurate coding.

6. Understanding Orthotics Billing Rules

Orthotics billing requires careful attention to bundling and unbundling. Some services must be billed together, while others are billed separately. Missteps can result in claim denials, making accuracy essential.

7. Ensuring Timely Claim Submission

Submitting claims promptly is key to smooth processing. Stay aware of insurance deadlines and maintain regular reporting to reduce the risk of denials and delays.

Final Thoughts

Orthopedic medical billing can be complex, but by staying informed of the correct codes and following payer-specific guidelines, you can streamline the process, minimize errors, and increase reimbursements. It’s crucial to regularly update your knowledge on changes in coding and regulations to avoid costly mistakes.

If you are looking for expert help with your orthopedic medical billing, EZ Settle Solution is here to assist. Our team specializes in medical billing and coding services, ensuring you receive maximum reimbursement without the hassle of navigating complex billing requirements. 

Contact us today for a free consultation!

Get started with EZ Settle Solutions!

Contact us at  346-335-4093 / info@ezsettlesolutions.com or schedule a free consultation to learn more about how we can assist you.

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