Most frequent denials. Following are the top 5 orthopedic billing claim denials by CPT code:

•    99213: Outpatient doctor visit, level 3
•    20610: Aspiration and/or injections; major joint or bursa
•    99203: Outpatient doctor visit, new patient, level 3
•    99214: Outpatient doctor visit, level 4
•    97110: Therapeutic exercises

The top 5 denial codes from the payers for orthopedic billing include:

•    45: Charge exceeds fee schedule
•    23: Prior payer(s) adjudication affected this payment and/or adjustment
•    18: Duplicate claim/service
•    59: Processed based on multiple or concurrent procedure rules
•    223: Mandated adjustment code when other code not applicable

What can you do about these?

Collect and analyze your data to determine your top denials.  Identify the root cause of all denial patterns, then develop processes to prevent these denials from occurring again.

Top solutions to denial problems include:

  • Coding audits and ongoing training
  • Eligibility verification processes
  • Utilizing a billing company that specializes in orthopedic billing


About Apache Health

Apache Health is a revenue cycle management (RCM) analytics, benchmarking, and auditing company. The founders of Apache formerly ran a large RCM company that was acquired by a private equity group in a rollup. Apache’s predictive analytics will benchmark billing performance and project exactly how much more revenue you should earn from your existing volume of patients.  Using many factors and a blend of artificial intelligence and specialty specific benchmarks, the model projects whether changing the billing process would improve collections for your particular mix of procedures and payers. Apache Health can help you evaluate whether to outsource the billing, determine which billing company to select to maximize performance, or track inhouse billing performance improvement over time. For more information contact:

Sean McSweeney

Apache Health