8 Tips to Help Avoid Orthopedic Coding Denials

Orthopedic practices face new coding and billing rules every year. Owing to time constraint, providers often fail to follow the new guidelines, which lead to incorrect claims and lost payments. There are numerous reasons why claims get denied by insurance companies. Monitoring the denials helps you to identify the root cause—is it because of payer not processing the codes correctly or is there an error in the practice management system.


Here are 8 essential billing tips to facilitate smooth, efficient billing process and avoid denials:

  1. Incomplete Information

The most common reason of denials from payers is inaccurate insurance information. A misspelled patient’s name or incorrect date of service can cause your claim to enter the denial pile. The billing staff needs to be competent enough to capture these details perfectly. Be diligent to the task of verifying insurance information with patients, and also make sure you have all essential and accurate details, such as, date and place of service, NPI of the referring and billing physician, etc.

  1. Local Coverage Determinations (LCDs)

According to CMS, LCDs are defined as “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).”—which means they differ based on which Part B Mac you’re billing. Always keep them handy to see your local rules and regulations.


  1. Incorrect Codes

In 2016, orthopedic billing changes includes, new codes to x-rays, E/M prolonged service codes, and paravertebral facet blocks. Apart from that there are reforms in payment for hip and knee surgeries. Keeping up with these coding changes are imperative for the billers, if they are using outdated CPT, ICD-10 or HCPCS codes, there are high chances of claims being denied by the payers.

  1. Modifiers

Appropriate use of a modifier will make or break your claims. For example, reporting a global code when someone else has already reported the same code with a Technical component modifier will lead to denial, however, when a modifier 26 (professional component) applies, your appropriate use of it will make or break your claim.

If you are appending modifier 52 (Reduced services) or 22 (Increased procedural services), some LCDs or NCDs will specifically indicate that you submit additional records. If you submit the code and modifier but fail to send in the appropriate documentation, your service will be denied.

  1. National Coverage Determinations (NCDs)

Learn the national rule on how to report a particular service from these directives. For example, for NCD of MRI procedures refer to: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R135NCD.pdf.

  1. Missing Deadlines

Submit the claims as soon as possible so that you don’t miss the payer’s deadlines. Note: different payers have different deadlines, and it’s important to keep a list of general payer deadlines, so as to track and document each payer’s receipt of claim submissions.

  1. Preauthorization Requirements of Insurers

Orthopedic surgeons often face difficulty in determining which tests and procedures require preauthorization by insurers; this leads to loss of claims settlement as they fail to abide by the preauthorization requirements of insurers.

  1. Automate the Billing Process

Coding errors can be largely eliminated by automating the billing process or outsourcing it out to a company that specializes in processing orthopedic claims. Integrating a computerized claims scrubber that checks claims prior to submission would be beneficial for the practices to avoid coding denials.


Reviewing the root causes of common denials and putting a process in place to avoid these denials in the future can assist in minimizing what can cost an orthopedic practice significantly in time and money. Expert speaker Lynn Anderanin will be sharing her views on some common orthopedic coding denials as well as denials being seen for ICD-10 coding, in an informative audio session. She will also review the trends in orthopedic coding denials currently being received by several practices and how to prove they are invalid.

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