Orthopedic practices face some of the most complex billing challenges in healthcare. Surgical modifiers, implant tracking, ICD-10 specificity, and payer variability drive denials that cost practices thousands every month. MedCare MSO’s orthopedic billing software layers AI into every stage of your revenue cycle so your team collects more and chases less.
The Problem
General billing systems were not designed with the high level of complexity of orthopedics in mind. Each joint replacement, spinal fusion, or implant comes with different coding rules, different payer requirements, and different levels of authorization before being approved. The result is denied claims, delayed revenue, and burnt-out billing departments.
Bilateral procedures, staged surgeries, and assistant surgeon claims all require precise modifier use. A single incorrect modifier triggers an automatic denial. Not one of your manual coding teams will be able to keep track of all possible conflicts between each of the payers’ specific rulesets.
Bone grafts, prosthetics, plates, and screws must all be tracked from the operating room to the final claim. When implant and device charges are mislinked, this is one of the largest areas of leakage that most practices cannot accurately measure or recover. Hidden revenue loss due to implant and device charge leakage in every surgical case.
Most elective orthopedic procedures require prior authorization before the surgeon ever touches the patient. If your front desk staff is doing this manually rather than having an automated workflow, they will have surgery delays and ongoing reimbursement gaps.
The musculoskeletal chapter in ICD-10 is one of the largest in the entire code set. Laterality, episode of care, and anatomical specificity requirements are easy to miss and hard to catch in review. One missed digit means a rejected claim or an audit flag.
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While competitors offer billing tools or services in isolation, MedCare MSO's AI ecosystem connects every touchpoint of your orthopedic revenue cycle into one intelligent platform. No stitched-together products. One cohesive system built for surgical billing complexity.
MedCare's MSO orthopedic medical coding software is the core of our system and automates the entire process from capturing charges to generating and submitting claims for all types of orthopedic surgeries, from fracture repairs to multi-level spinal fusions. Each claim for an orthopedic service is generated using AI technology that ensures accuracy before submitting it.
ERA totals are reconciled against BAI/NACHA bank deposit files before posting begins. Each batch will balance down to the penny.
Our medical payment posting specialists handle paper and scanned Explanation of Benefits documents with accuracy applied to electronic ERA files. We read thoroughly into the remarks, calculate the appropriate amounts that can be billed to you, post the contractual adjustments to the patient’s account balance based on your EOBs and then post the difference between the allowed amount and your balance as patient responsibility.
Paper EOBs are digitized, extracted, and posted within 24 hours.
We post zero-payment EOBs with complete denial capture. We maintain visibility to each denial code as you need to use it to take action on a denial management team level, without collapsing it into generic write-off categories to hide the root cause.
Denial trend reporting from clean posting data enables upstream corrections through the AI Rule Engine, therefore, reducing the same denial reason recurring across future claims.
Payments from all channels (the portal, via the phone, etc.) are processed for patients on a daily basis. Copays, deductibles, coinsurance, and self-pay balances are adequately posted to their corresponding service lines with clear audit trails, and patients should receive accurate statements for all of these payment types.
By accurately posting payments from patients, the likelihood of billing disputes is reduced. Patients collect money more quickly, and statements to the patients will accurately communicate their actual balances, with balances for copays, deductibles, and coinsurance.
AI selects the correct CPT codes and validates modifier combinations for bilateral procedures, staged surgeries, and assistant surgeon claims before submission. No manual modifier lookup required.
Bone grafts, prosthetics, plates, and screws are tracked from the OR through to the claim submission process. Every device charge is automatically linked to the appropriate procedure code and payer documentation requirement.
Submitting authorization requests, tracking payer approvals, and receiving alerts for pending or denied authorizations will reduce delays in scheduling surgeries due to having to manually follow up with payers.
Verify patient eligibility and benefits prior to each orthopedic encounter. You're able to identify coverage gaps, deductible limits & network status issues as a front end of a costly post-service billing dispute.
Using AI technology, you can identify denied orthopedic claims and process them in the correct workflow. Also, we are automating the generation of appeal letters with appropriate supporting documentation to stop losing revenue due to unworked denials.
Handle both facility and professional fee billing for ambulatory surgical centers natively. Implant passthrough billing, UB-04 claim generation, and outpatient compliance built into one platform.
Surface collection trends, payer performance, denial root causes, and outstanding balances in real-time dashboards. Make revenue decisions with data, not guesswork.
Connect with your existing EHR and practice management system without ripping and replacing. MedCare MSO's healthcare integration services support all major orthopedic platforms.
Automate repetitive billing tasks, including payment posting, patient statement generation, and eligibility batch verification with RPA-powered workflows.
See how MedCare MSO’s AI-powered orthopedic billing software transforms your revenue cycle from first claim to final payment.
All denials post with the original CARC Codes, such as co-97 (bundled), co-16 (missing info), co-22 (other payer), co-50 (medical necessity), and the PR series (responsible for the Patient). This provides your denial management team with clean data for appeals.
27447
27130
27487
22633
22853
22102
29827
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29826
Orthopedic implants, including prosthetics, bone screws, and spinal hardware, are reported using HCPCS Level II codes alongside CPT procedure codes. Incorrect or missing HCPCS codes are a leading cause of underpayment on surgical claims.
According to CMS (Centers for Medicare and Medicaid Services) regulations, high-cost orthopedic implants used in Ambulatory Surgery Centers (ASC) may be eligible for pass-through payment under an ASC facility billing UB-04 claim using revenue code 0278, with a separate HCPCS number assigned to the device to ensure the cost is not absorbed into the ASC’s APC (Ambulatory Payment Classifications) payment.
Orthopedic ASCs are required to submit a UB-04 claim for the facility fee separately from the surgeon’s professional fee submitted on a CMS-1500 claim. MedCare MSO provides a seamless workflow for both types of claims, with the implant cost automatically connected to the appropriate procedure line
No matter what type of orthopedic practice you operate, from an independent clinic to managing a multi-site ASC or group practice, MedCare MSO's HIPAA-compliant orthopedic billing software scales to your size without changing how you work.
Get the full power of AI-assisted billing without needing to hire an in-house billing team. Cost-effectively automate charge capture, coding, and claim submission with a small support staff whose primary focus is patient care, not getting paid.
Standardize coding across your multi-physician group while eliminating the need for separate billing systems by using one central system and providing your providers with individual reports.
Facility fee and implant billing are built into one workflow. Handle UB-04 claims, device passthrough billing, and outpatient compliance requirements without juggling multiple systems or workarounds.
Continue to scale your orthopedic billing business without increasing your workforce or error rate by using AI-assisted workflow capabilities to manage multiple orthopedic providers.
Every element of MedCare MSO's medical billing software for orthopedic practices is designed and maintained to meet the strictest healthcare data security and compliance standards.
We provide chronic care management billing services and support PCM CPT codes, including 99490, 99439, 99487, 99489, 99491, and PCM codes, with strict monthly time tracking and documentation validation before billing.
Our fee is a transparent starts from 2.99 % of net collections—no hidden charges.
We import your payer rules, set up ERA/EFT, and go live in 14 days.
CCM can be billed once per calendar month per patient when at least 20 minutes of qualifying non-face-to-face care is provided and documented.
Bill 99490 for the first 20 minutes of CCM time and 99439 for each additional 20 minutes in the same month when time thresholds are met.
CPT 99490 requires patient consent, an active care plan, and at least 20 minutes of non-face-to-face care per month documented by clinical staff.
Yes, Medicare covers CCM services for eligible patients with two or more chronic conditions expected to last at least 12 months.
Medicare does not cover therapy itself under CCM, but care coordination and management activities related to chronic conditions are covered.
CCM services can be billed by physicians and qualified healthcare providers, such as NPs and PAs, who oversee patient care. Our billing for CCM services supports providers by managing enrollment, documentation, coding, and compliance to ensure accurate and timely reimbursement.
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