We understand the orthopedics specialty, let us help you drive revenue and build your business.
Orthopedics billing is complicated and covers a wide scope of services and procedures, and the wise choice for outsourcing the billing is to choose a company that is experienced in this unique specialty.
The high dollar, low volume (compared to most practices) nature means that every patient encounter needs to be accurately documented, coded, billed, and collected. The high deductible world of medicine also mandates an efficient yet patient friendly system for verifying insurance coverage and collecting patient responsibility balances both up front and after insurance has paid.
What we know…
FAI (Femoro-Acetabular Impingement) Surgery – Many insurance carriers consider this surgery experimental (investigational) or have very strict guidelines on when they will cover the procedure(s). Documentation in the patient’s medical record of the following is an example of what a carrier will use to determine coverage:
Diagnosis of definite femoro-acetabular impingement defined by appropriate imaging studies ( X-rays, MRI or CT scans), showing cam impingement (alpha angle greater than 50 degrees), pincer impingement (acetabular retroversion or coxa profunda), or pistol grip deformity (nonspherical femoral head shape).
Severe symptoms typical of FAI (hip pain that is worsened by flexion activities (e.g., squatting or prolonged sitting) that significantly limits activities, with duration of at least six months where diagnosis of FAI has been made as above.
Positive impingement sign with sudden pain on 90 degree hip flexion with adduction and internal rotation or extension and external rotation.
Failure to respond to all available conservative treatment options including activity modification (e.g., restriction of athletic pursuits and avoidance of symptomatic motion), pharmacological intervention and physiotherapy.
Member is 15 years of age or older or skeletally mature (as indicated by epiphyseal closure)
Absence of advanced osteoarthritis change on preoperative Xray (Tonnis grade 2 or more) or severe cartilage injury (Outerbridge grade III or IV).
Absence of joint space narrowing on plain radiograph of the pelvis. Joint space is not less than 2 mm wide anywhere along the sourcil.
Member does not have generalized joint laxity especially in diseases connected with hypermobility of the joints, such as Marfan syndrome and Ehlers-Danlos syndrome.
Member does not have osteogenesis imperfecta.
Please review carrier guidelines and policies carefully. Some may require prior approval for surgery, others may allow review of medical record postoperatively to determine medical necessity and coverage.
Viscosupplementation (Euflexxa, Gel-One, Gel-Syn, Genvisc, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz, Synvisc, Synvisc-One) – Many insurances consider the injection of one of these drugs into a joint to be not medically necessary, experimental (investigational) or have strict guidelines when it is covered. Please refer to carrier policies for guidance and coverage. Most carriers when coverage is allowed will only do so for the knee. Most carriers require the following documentation in the medical record for coverage of viscosupplementation for osteoarthritis of the knee:
Conservative therapy (including physical therapy, pharmacotherapy (e.g., non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen (up to 1 g 4 times/day) and/or topical capsaicin cream)) has been attempted in each joint to be treated with viscosupplements and has not resulted in functional improvement after at least 3 months or the member is unable to tolerate conservative therapy because of adverse side effects;and
The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts, or, if radiographs are not available, the member has documented symptomatic osteoarthritis of the knee according to American College of Rheumatology (ACR) clinical and laboratory criteria, which requires knee pain and at least 5 of the following:
Crepitus (noisy, grating sound) on active motion
Erythrocyte sedimentation rate (ESR) less than 40 mm/hr
Less than 30 minutes of morning stiffness
No palpable warmth of synovium
Over 50 years of age
Rheumatoid factor less than 1:40 titer (agglutination method)
Synovial fluid signs (clear fluid of normal viscosity and WBC less than 2000/mm3); and
The member has failed to adequately respond to aspiration and injection of intra-articular steroids; and
The member reports pain which interferes with functional activities (e.g., ambulation, prolonged standing); and
The pain cannot be attributed to other forms of joint disease; and
The member is not scheduled to undergo a total knee replacement within six (6) months of starting treatment; and
There are no contraindications to the injections (e.g., active joint infection, bleeding disorder, skin infections at the injection site).
Also keep in mind that most carriers require a six month interval between treatments and some carriers are now requiring nine months between treatments with a viscosupplementation drug.
On October 1, 2016 the Centers for Medicare and Medicaid Services (CMS) will no longer accept unspecified codes in most cases.
Starting in October, CMS requires greater specificity for claims filed in ICD-10-CM/PCS. The 12-month grace period originally introduced in 2015 said they would not deny claims for lack of ICD-10 specificity. That all changes on October 1, 2016. Payors will most likely follow suit if they haven't already.
First Pass Clean Claim Rate
Boost in Revenue*
Reduction in Cost*
Although the new industry standards can be confusing and difficult to navigate, our dedicated team here at Etransmedia can assist in guiding you and helping to make your practice grow successfully.
*Please Note: Results are not guaranteed, implicitly or explicitly, and will vary based on several factors such as individual practice demographics, specialty, payer mix, operations, and management among others
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