Orthopedics billing and accounts receivable

Global periods, modifier 25 and 59 scrutiny, and implant billing make orthopedics one of the most audited specialties.

Where the money leaks in orthopedics

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Modifier 25 denied on an E/M billed the same day as a procedure
• Services inside a 90-day global period billed separately
• Implant and hardware charges denied for missing invoice documentation
• Bilateral procedures billed as two lines instead of modifier 50
• Physical therapy denied for exceeding the therapy cap without a KX modifier

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working orthopedics, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-16 — Claim lacks information
  Something on the claim is missing or malformed. On its own the code tells you nothing — the detail is in the remark code that comes with it.
  Recovered by being corrected and resubmitted. Matched from: “Modifier 25 denied on an E/M billed the same day as a procedure”
• CO-50 — Not deemed medically necessary
  The payer does not accept that the documentation supports the service. This is a clinical argument, not a clerical one.
  Recovered by being appealed with clinical documentation. Matched from: “Implant and hardware charges denied for missing invoice documentation”
• CO-4 — Modifier and code disagree
  The code and the modifier disagree, or a modifier the payer required was not there.
  Recovered by being corrected and resubmitted. Matched from: “Bilateral procedures billed as two lines instead of modifier 50”
• CO-11 — Diagnosis and procedure disagree
  The payer does not accept that the diagnosis submitted justifies the procedure performed.
  Recovered by being corrected and resubmitted. Matched from: “Physical therapy denied for exceeding the therapy cap without a KX modifier”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a orthopedics AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions