Are you an orthopedic physician struggling with the intricate coding and billing process for your rendered care services? If yes, you have landed at the right guide! This guide is dedicated to answering your billing and coding challenges and helping you rise above the competition.
We will discuss the orthopedic billing guidelines to help you understand what factors to consider and mistakes to avoid while billing for services to avoid payment delays and denials. Besides, we will share a list of essential orthopedic CPT codes.
Understanding CPT Codes for Orthopedic Procedures
Regardless of the specialty, accurately coding the rendered services is the primary requirement to get your rightful reimbursements on time. Orthopedic is no different!
Thus, to help you maintain a steady cash flow and smooth operations, this section will discuss the common orthopedic CPT codes for surgical procedures. We will also share other commonly used CPT codes required for billing orthopedic services, along with the relevant modifiers.
Essential Orthopedic CPT Codes for Billing
Here’s a list of essential orthopedic CPT codes required for billing:
| CPT Codes | Description |
|---|---|
| Surgical Procedures – (10021-69990) | These codes cover various orthopedic surgical procedures; from simple repairs to complex replacements. |
| Anesthesia – (00100-01999 & 99100-99140) | This range encompasses the anesthesiologist services; from pre-operative evaluation to monitoring the patient’s vital signs and administering anesthesia during surgery throughout the orthopedic procedure. |
| Pathology &Laboratory – (80047-89398) | They represent pathology services and laboratory tests performed on tissue samples for diagnosis and deciding the most suitable treatment plan. |
| Evaluation & Management (E/M) – (99201-99499) | You can use these codes for billing physicians’ performed E/M services, covering the complexity and time required to examine the patient, establish a diagnosis, and develop a treatment plan. |
| Radiology – (7010-79999) | This code set indicates various imaging services such as MRIs, X-rays, CT scans, and MRIs for diagnosing and monitoring different orthopedic conditions. |
| Medicine – (90281-99299 & 995001-99607) | These codes represent medical services not categorized elsewhere, such as wound care, medication administration, and injections. |
Common CPT Codes for Orthopedic Procedures
The following are the commonly used CPT codes for orthopedic procedures:
| CPT Codes | Description |
|---|---|
| 23000-23929 | These CPT codes are related to various shoulder surgery procedures, such as joint replacement, arthroscopic surgeries, and rotator cuff repairs. |
| 23930-24999 | This CPT code range encompasses humerus (upper Arm) and elbow surgery procedures, including tendon repairs, ligament reconstructions, and fracture repairs. |
| 25000-25999 | They represent various procedures on the wrist joint and forearm bones (radius and ulna), such as tendonitis treatment, fracture fixation, and carpal tunnel release. |
| 26010-26989 | This CPT code range covers procedures on the fingers and hands, including fracture fixation, tendon repairs, and trigger finger release. |
| 22010-22899 | This range covers various spinal (vertebral column) procedures, such as decompression, fusions, and disc replacement surgeries. |
| 11760 | It represents nail bed repair. |
| 25215 | This CPT code is for carpectomy, all bones of the proximal row. |
| 64721 | It is used to bill neuroplasty and/or transposition – the median nerve at the carpal tunnel. |
Common Modifiers Used in Orthopedic Billing
Using relevant modifiers is equally important with CPT codes to get timely payments. Discussed below is a list to help you get started!
| Modifiers | Descriptions |
|---|---|
| Left side (LT) | It is used when a procedure or service is performed on the left side of the body. |
| Right side (RT) | It is used when a procedure or service is performed on the right side of the body. |
| Bilateral procedure (50) | It means the procedure or service is performed bilaterally. |
| Multiple procedures (51) | It identifies that the physician performed multiple procedures during the same session. |
| Reduced service (52) | It means a procedure or service was eliminated or partially reduced at the physician’s discretion. |
| Repeated procedure by the same physician (76) | It indicates the repetition of a procedure by the same healthcare provider. |
Orthopedic Billing & Coding Best Practices
If you want to stay on top in the competitive healthcare landscape, ensuring a steady cash flow is optimal. Thus, this section will present you with orthopedic billing and coding guidelines to ensure clean claim submission for faster reimbursements and reduced denial rate.
So, without stalling, let’s start with the orthopedic coding guidelines:
Obtain Prior Authorization
One of the orthopedic billing guidelines for a higher claim first-pass rate and reducing the likelihood of denials is to obtain prior authorization from the insurance payer before rendering orthopedic procedures to patients.
We advise you to perform prior authorization every time before rendering care services because every insurance payer has different policies and requirements.
Besides, payer policies are subject to regular updates and changes, so assuming specific services are allowed by a payer can only lead to payment delays or denials.
Ensure Detailed Documentation
Complete and accurate documentation is another orthopedic billing guideline you should not take for granted. It enables you to establish the medical necessity and appropriateness of the provided procedure or service and helps you get maximum reimbursements.
Thus, focus on maintaining detailed records of the patient’s medical history, treatment plans, physical examination, diagnostic tests, performed procedures, complications, post-operative care, and follow-up encounters.
Comply with Coding Standards
Next in orthopedic coding guidelines comes the compliance with state and federal regulations related to coding the orthopedic procedures. Thus, you should invest in proper certification and specialized training related to orthopedic coding guidelines and ensure all rendered services or procedures are billed using accurate CPT codes.
Besides, using relevant modifiers is crucial, providing further clarity to the insurance payer. For example, you may use the modifier LT if the physician performed the procedure on the left side of the body.
Moreover, coding guidelines are subject to regular updates and changes. As a result, you must stay current on any changes in orthopedic-related codes to avoid denials and payment delays affecting your practice’s revenue cycle. Also, conducting regular internal audits will help you identify and address billing and coding issues, minimizing the risk of legal issues or financial penalties.
Follow the Bundling or Unbundling Rules
Another best practice to avoid billing blues is understanding and adhering to bundling and unbundling rules of orthopedic services or procedures. Some procedures are bundled together and should not be billed separately, as individually reporting them may result in overcrowding, leading to penalties or denials.
For example, the CPT code 29870 indicates the arthroscopic removal of a torn portion of the medial meniscus in the knee. This code is bundled with the CPT code 29850, which represents arthroscopic visualization of the knee joint.
Thus, follow the appropriate bundling of CPT codes to prevent billing separately for procedures already included in the primary code.
Bottom Line
Following orthopedic billing guidelines will help you streamline your workflow and optimize your healthcare facility’s financial health. You can use the common CPT codes and modifiers to accurately bill orthopedic procedures and collect timely reimbursements.
However, if you find it difficult to do it yourself with all your clinical responsibilities, you can get professional orthopedic billing services from a reputable medical billing company like MediBill MD.
