The best way to keep your income stream flowing properly is to prevent claim denials.

cash flow

You should be aware of the following high volume denial reason codes and prepare a strategy to keep them to a minimum in your practice.

By utilizing an advanced Medical Practice Management Billing Software like Iridium Suite from Medical Business Systems, many of these types of denials will become a thing of the past.

duplicate claim18 - Duplicate claim/service.

Manual keying of services lends itself to duplicate entry of those services.   A configurable Claim Scrubber as found in Iridium Suite will check each service entered and alert the user immediately if the same service is already on record.

claim lacks information  16 - Claim/service lacks information which is needed for adjudication.

Some payers have specific claim rules that require “non-standard” 5010 format information be included on their claims.  An example is the rendering provider’s Taxonomy code in addition to the standard NPI.  Iridium Suite allows the user to include this specialized data on the claims to those individual payers as needed. 

payment included in another service97 - Payment is included in the allowance for another service/procedure.

Government payers, such as Medicare, as well as the larger Commercial payers have adopted the NCCI standard for “bundled” services.  The Iridium Suite Claim Scrubber comes standard with all current NCCI edits built in.  The Scrubber alerts the user when entering two or more procedures that are considered inclusive of each other.

Time filing limit has expired  29 - The time limit for filing has expired.

Payers each have their own time filing limits guidelines for claim submission.  It can be as short as 60 days, or the current Medicare limit is 12 months.  The sooner you submit your claims, the quicker. 

you will receive your payment and eliminate the risk of untimely filing denials. 

Connectivity Clearinghouse within Iridium Suite, you can import patient demographic and service data directly into the billing software from your EHR/EMR.  Your patient and charge entry process can be almost completely automated allowing for close to “real time” claims submission for your services.

non-covered service50 - These are non-covered services because this is not deemed a ‘medical necessity by the payer.  

The key to preventing these types of denials is being aware of your payers Medical Policies. These two Biller’s Blogs provide insight on both Commercial Payers and Medicare:

Reviewing Commercial Carrier Medical Policies

Understanding Medicare Fiscal Intermediaries LCD's

identification number and name do not match140 - Patient/Insured health identification number and name do not match.

By utilizing the Real Time Eligibility function in  

Iridium Suite, you can virtually eliminate denials 

like the one above or similarly “subscriber not  eligible

at time of service.”  You will be able to successfully 

submit charges to the correct active payer with the 

proper identification number and receive your  

appropriate claims reimbursement on the first submission. 

Absence of precertification197 - Payment adjusted for absence of precertification/authorization.

2013 Orthopedic Surgery CPT Code Changes and Additions

These are the highlights of the seven CPT code changes and a listing of numerous CPT code additions affecting Orthopedic Surgery billing in 2013.  Make sure you review the full CPT manual for complete details of all coding changes to insure you receive your optimum claim reimbursements.

Increased Claims Reimbursement

Spine CPT

Guideline Change: CPT codes 22633 and 22634 may be appropriately related as primary or index codes for spine bone grafts (20930–20938), instrumentation (22840–22844, 22848, 22845–22847), and intervertebral device (22851) codes. 

 Bone marrow aspirate

Clarification: Use of bone graft codes (20930–20938) related to bone marrow aspiration. CPT code 38220 defines the work associated with the harvest of bone marrow for bone grafting only. (Billing Note: Category III code 0232T should be used when bone marrow aspiration is performed for platelet-rich stem cell.)

Cervical Spinal Arthrodesis Guideline

Guidelines Added:  CPT codes 22554, 22585, 63075, and 63076; if the work associated with these procedures is performed during the same surgery by the same surgeon or by two separate surgeons/individuals during the same session, the correct codes are 22551 and 22552. (Billing Note: CPT codes 63075 and 22554 may not be unbundled and reported for the same patient, same session.)

Cast application

Guideline Change:  Refer to the section “Application and Strapping” for specific changes regarding the application of the first cast, its removal, coding by the individual who performs the initial service, and restorative management. (Billing Note: CPT code 29590 (Denis-Browne bar (splint) with manipulation and casting (eg, for metatarsus adductus, clubfoot) was deleted.)

Hip arthroscopy

Clarification: CPT code 29916 (Arthroscopic labral repair of a torn labrum) is considered inherent to CPT codes 29915, 29862, and 29863. (Billing Note:  CPT code 29916 should not be reported in addition to CPT codes 29915, 29862, or 29863 because the repair is already included in these codes, whether as a takedown and repair or a repair of an already torn labrum.)

Chemodenervation

Guideline Change:   CPT code 64614 (Chemodenervation of muscle(s); extremity and/or trunk muscle(s) (eg, for dystonia, cerebral palsy, multiple sclerosis) may only be reported once per extremity. The parenthetical (s) was removed from extremity. (Billing Note:  CPT code 64614 states that modifier 50 should not be appended to this code. Check with your payers to determine specific rules to code submission.)

Intraoperative nerve monitoring

Clarification: Intraoperative nerve monitoring by the operating surgeon is included in the primary surgical service and is not separately reportable.

Update your medical billing system with the following new CPT codes for 2013: Spine

22586—Arthrodesis, pre-sacral inter-body technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace

0309T—Arthrodesis, pre-sacral inter-body technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft, when performed, lumbar, L4-L5 interspace (Billing Note: List 0309T separately in addition to code for the primary procedure 22586)

Shoulder Arthroplasty

23473 - Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component.

23474 - Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component.

Elbow Arthroplasty

24370 - Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar component.

24371 - Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar component.

Nerve Conduction

(Billing Note:  Guideline instructions related to the reporting of electromyograms (EMGs) and nerve conduction studies (NCS) are found in the beginning of their respective CPT sections.)

 CPT codes 95900–95904 were deleted and replaced by the following CPT codes: 

95907—Nerve conduction studies; 1–2 studies

95908—Nerve conduction studies; 3–4 studies

95909—Nerve conduction studies; 5–6 studies

95910—Nerve conduction studies; 7–8 studies

95911—Nerve conduction studies; 9–10 studies

95912—Nerve conduction studies; 11–12 studies

95913—Nerve conduction studies; 13 or more studies

Extracorporeal Shock Wave: Wound Healing

Two new Category III codes for extracorporeal shock wave for wound healing were introduced:

0299T—Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound

0300T—Each additional wound (Billing Note:  List separately in addition to code for primary procedure.)

With Iridium Suite practice management software, you can take the worry away from all of these changes. This medical billing software is loaded with all current CPT I, II, III and HCPCS Level II codes as well as the NCCI edits.  It also has the Claim Scrubber function, allowing you to create special billing rules so you don’t forget to bill those “companion” codes.