For orthopedic practices, there are new coding and billing rules coming in every year that they have to adhere to. If these are not followed, it may lead to incorrect claims and subsequent losses in payments. There are many reasons why an insurance company might deny a claim, and watching these is the best way to know what to avoid when processing the codes and managing the process.
Here are some things to watch to ensure smooth, efficient billing and avoid denials.
Incomplete Information
The reason why payers most commonly deny claims is that all the insurance information has not been spelled out properly. Misspelling the patient’s name or inputting the date of service can cause claim to head to the denial pile. The billing staff will need to be competent enough to provide these details perfectly. It is important to be diligent when verifying insurance data with patients, and it is doubly vital to ensure that you have the right details down, such as date, place of service, NPI of the referring and billing physician, etc.
Local Coverage Determinations
As per CMS, “For purposes of this section, the term ‘local coverage determination’ means a determination by a fiscal intermediary or a carrier under part A or part B, as applicable, respecting whether or not a particular item or service is covered on an intermediary- or carrier-wide basis under such parts, in accordance with section 1862(a)(1)(A).” This means that they will differ on the Part B Mac that you are billing. Keep these handy so you can refer the local rules and regulations.
Incorrect Codes
This year, orthopedic billing changes include new codes to x-rays, E/M prolonged service codes and para-vertebral facet blocks. Aside from this, there are also reforms in the payment for hip and knee surgeries. Staying updated with these changes will definitely help billers. On the other hand, if they are using outdates CPT, ICD-10 or HCPCS codes, there is a fair chance of most claims being denied by insurance companies.
Modifiers
The right use of a modifier is what will make or break your claims. You could be reporting a global code with which someone has already reported, and if they have used a technical modifier, you could get a denial. However, if modifier 26 is applicable, the right use of this can decide successful payment reception. Appending modifier 52 (Reduced services) or 22 (Increased procedural services), may lead to the requirement for additional record submission. Make sure that all modifier use is backed up with the appropriate documentation.