ASC Orthopedic Billing Services

Orthopedics represent one of the fastest growing specialties in ASC’s with over 20% of surgery center procedures classified as orthopedic (per the ASC Association). Favorable trends in Medicare reimbursement have continued to accelerate the growth of orthopedic procedures in a surgery center setting. Of course, continued improvements in technology and anesthesia are also important factors. Patients are also increasingly receptive to outpatient orthopedic procedures as they find the environment of an ASC more attractive than many hospital settings.

3 Practical Steps to Improve ASC A/R. Download Whitepaper

Skills required for ASC Orthopedic Billing

Billing for ASC orthopedic procedures is particularly complex. Orthopedics represents a wide variety of procedures (some examples are listed below) and underlying causes (diagnoses). Often rules vary by payer (e.g. modifiers). As a result, it is recommended that only experienced orthopedic coding and billing staff be employed. To perform effectively, billing staff must be knowledgeable in coding, charge posting, claims filing, payment posting, customer service, A/R follow-up including denial management, and reporting.

For many centers, finding and retaining these skills in a relatively small staff can be a challenge. For this reason, hiring a firm who specializes in ASC orthopedic billing may be the best option. The right firm offers an ASC the ability to hire a team of experts, specialized and skilled in each of the billing disciplines, while only paying for a fraction of the costs. Since a professional ASC billing company performs coding and billing for many ASC’s, economies of scale are realized and passed along to clients. The volume of work justifies having specialists and experts and avoids the risk that an ASC faces with internal staffing: “jack of all trades, but master of none.”

Billing Considerations for ASC Orthopedics

Insurance underpayments are an issue for all specialties, but they can be particularly common, and troublesome, for ASCs specializing in orthopedics. Uunderpayments can represent 10% or more or a surgery center’s revenue. Multi-procedure rules are one example where tracking payments is critical to assuring proper reimbursement.

Patient billing can also be complex for orthopedic ASCs. Many patients see expensive procedures (an average charge of over $8000 per case according to VMG Health, LLC), complicated payor explanations, and bills from other specialists (e.g. anesthesiologist) often lead to confusion. Billing staff and procedures built to offset these roadblocks can be much more successful in collecting patient balances in a timely manner.

As everyone knows, coding rules for orthopedics are constantly changing. The addition of new procedures (and their associated codes) is important.

However, for most orthopedic surgery centers, careful coding of common orthopedic procedures is even more important. At its most basic level, this means coders must carefully review the operative note to make sure they’ve accurately and completely captured exactly what was done. As an example, others have commented that lipoma removals, fracture care, hardware removals, and tendon grafts with ACL repairs are frequently mis-coded, usually resulting in lower reimbursement and/or non-compliant billing. With average reimbursement per case in the area of $2,000 (VMG Health Intellimarker), many centers may be overlooking some of these “smaller” considerations, and leaving 10% or more “on the table.”

Selected ASC Orthopedic Procedures

Is your ASC performing many or most of these procedures? How about the 100’s of others performed daily in ASC’s around the country? Are you confident that you are being fully reimbursed? If not, ask us about a free surgery center financial analysis.

Obtaining small amount of bone for graft (CPT 20900)
Open surgical partial removal of collar bone (CPT 23120)
Partial repair or removal of shoulder bone (CPT 23130)
Open repair of rotator cuff, recent (CPT 23410)
Open repair of rotator cuff, old (CPT 23412)
Reconstruction rotator cuff, old (CPT 23420)
Open repair elbow fracture involving ulnar bone (CPT 24685)
Wrist fracture pinning through skin (CPT 25606)
Open surgical treatment wrist fracture (radius) (CPT 25607)
Shoulder scope, repair cartilage tear (CPT 29807)
Shoulder scope, partial removal collar bone (CPT 29824)
Shoulder scope, bone shaving (CPT 29826)
Shoulder scope, rotator cuff repair (CPT 29827)
Injection of lower back joint (HCPCS G02060)Note: CPT codes are copyrighted by the AMA.