Accurate Coding Slashes Orthopedic Claim Rejections by 74%.

About the Client

The practice is an established orthopedic practice in Texas that operates at five different sites within the state, including eighteen clinicians involved in orthopedic surgery, sports medicine, and joint reconstruction. The practice has seen steady growth over time due to their natural growth and incorporation of smaller practices with different internal processes that predated centralization.

At the time when the leadership of the revenue cycle decided to conduct an official audit, it became evident that what once was an easily manageable system had turned into an organizational weakness. There were billing differences at various locations, resulting in frequent denials that could have been avoided, and their first-pass success rate for claims had fallen to a level where reworking the claims took up more time than necessary.

The Client’s Challenge

Modifier Chaos Across Locations

Given the existence of five distinct locations, all functioning independently of one another, there was no coding guideline that had been set out in place yet. Different understandings existed regarding whether the 59 modifier was applicable rather than the more specific ones such as XE, XS, XP, and XU. Inconsistent application of the LT and RT modifiers was noted due to the variation in the person assigned with the task of doing the coding work on a specific date.

The effects of these issues were far-reaching. Insurance carriers highlighted bundling scenarios that failed to comply with the correct coding initiative edits, the stacking of modifiers automatically resulted in a downcode, and differences in laterality produced incongruities between operative reports. The clean claims rate of the practice, which had never been measured previously at the aggregate level, was found to be well below the industry average.

Surgeon Documentation Gaps

This second line of demarcation existed within the operative report itself. The surgeons in the group were not trained in the intricacies of billing. Instead, they drafted reports that were detailed enough from a medical perspective but lacking in the details needed for precise coding of implants, justification of multiple procedure codes, and proof of medical necessity to justify any additional CPT codes.

In other words, the coders were forced to default to the most conservative code possible, meaning missed revenue for the group, or to spend hours calling back the operating surgeon to get a detailed addendum.

Solution

Instead of implementing point solutions for individual issues, the engagement took the approach of viewing the entire revenue cycle process as a holistic system. Three different yet interrelated streams of work began simultaneously, focusing on different levels of the challenge.

Specialty Coding Rules Engine

Specialized orthopedic edit guidelines for bundling of surgery, modifier ordering, and device reimbursement prevent mistakes before the claim even goes out to the insurance company.

The rules engine was based on a database of edits for orthopedics based on CMS’s correct coding initiative, commercial payer rules, and the practice’s own two-year claims history. Unlike generic scrubbers for clearinghouses that lack context about the type of case being evaluated, the rules engine recognized that if a patient had a primary shoulder arthroplasty procedure with its associated CPT code, the engine would recognize bundling ramifications for the component codes and that the X-descriptor should be used, not just modifier 59.

EHR-Integrated Charge Capture

CPT codes are populated automatically by the electronic medical record from the operative report without manual coding delays, and claims lag from days to same day.

As far as integration with the group’s EHR system is concerned, it helped in pushing the operative note information automatically into the charge capture process. This involved having a translation layer that mapped the terminology used in the notes to the relevant CPT codes based on which coders entered final codes without needing to look up CPT tables or transcribe notes manually.

Quarterly Provider Education

Workshops aimed at surgeons target the highest priorities to instill documentation standards while providing care, not as an afterthought.

The education program was based on the denial data specific to the practice and not the guidelines on coding that were available. The first activity in each quarterly meeting was the analysis of the top five denials during the previous quarter in clinical language to help the surgeon identify their own note writing style. Each meeting lasted only forty-five minutes, and both face-to-face and video recordings were offered to fit into the surgeon’s schedule.

Results, Outcomes, and Forward Plans

We were spending far too much time fixing errors rather than creating new claims. In less than six months, we had converted a recurring liability into an income generator. We’re collecting more money, we have almost no re-work anymore, and we know the value of the surgeons’ documents.

— Managing Partner & Lead Surgeon, Multi-Location Orthopedic Group, Texas