Explain Medical Necessity And Its Relationship To Icd-10-Cm Diagnosis Codes Prosthetic Billing Outsourcing: Why It’s Important

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Prosthetic Billing Outsourcing: Why It’s Important

Prosthetic billing outsourcing is quite a common practice among the healthcare providers, orthopaedics, and DME sellers. The basic reason is the inability of the in-house staff to handle the typicality of billing of prosthetics and orthotics. Often subjected to a copay and/or coinsurance, orthotics and prosthetics coverage demands different requirement for various devices and varies according to payers. This should come within the member’s benefits provisions. A prosthetic biller has a lot to do. That includes:

• Collect prescription from the ordering physician dated prior to delivery date.

• Consider the limitations of the item covered based on the fixed time period. Example: A pair of Orthotics shoes is covered per the calendar year by Medicare.

• Bill appropriate modifiers.

• Check letter of medical necessity and additional documentation as required for some devices. Example: PPR form for prosthetic devices.

• Check the coverage of devices subject to qualifying diagnosis.

• Consider repairing or replacing and supply for separate reimbursement as per eligibility.

Most providers, orthopaedics, and DME companies see their billing staffs spend a lot of time countering these operations that prove quite time-consuming and burdening as they are already stuffed with various responsibilities. Add to it the in-depth knowledge of reimbursement guidelines of Medicare, Medicaid and Commercial Plans, their caveat etc. needed to carry out these jobs expertly. Operational inefficiency in these areas directly affects the cash flow as claims denials increase and account receivable collection takes a blow. This is why you need to consider prosthetic billing outsourcing.

Prosthetic Billing Outsourcing: How it helps

A dependable medical billing service that offers prosthetics (and orthotics) billing solutions will provide you with a host of functions including:

Eligibility Verification

• Check Policy active for a date of service

• Check Co-pay / Coinsurance / OOP, Rx & Dx entry

• Check Provider status

• Check Authorization requirement

• Obtain authorization

Authorization Verification

• Follow-up till resolution and closure

• Complete the authorization process with efficiency

• Follow-up p periodically to maintain authorization validity

Medical Coding

• Place of Service Based Coding: Inpatient and Outpatient Coding

• Provider Specialty Based Coding: E/M, Cardiology, Orthopedics, Physical Medicine, etc.

• Assign proper ICD-10 codes for the diagnosis

• Assign modifiers as applicable

• Code review and quality assurance

• Communication with Physician’s office for any extra medical documentation and required clarification

A/R Analysis

Analyze A/R

Follow-up with payer

Closure of claims

Denial Management

• Claim Correction

• Resubmissions

• Patients’ Responsibility

However, you need to be really careful to look for a billing partner that can take care of your prosthetic billing needs within your budget and provides you with an end-to-end Revenue Cycle Management/Practice Management solution.

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