Orthopedics Payment Posting Software

Payment Posting in a Orthopedics Practice

In an orthopedic group, one 835 file can hold a knee arthroscopy paid under multiple-procedure rules, a post-op visit denied as part of the global package, and a hyaluronic acid injection paid per unit. Payment posting starts when the system imports that file from the clearinghouse and matches each service line to the charge it pays. A CARC 59 reduction on a secondary procedure is checked against the amount the practice expected. A CARC 97 denial on a visit inside the global window is flagged, so staff can see whether modifier 24 or 79 was missing or the denial is correct. Contractual adjustments, deductibles and takebacks post as separate lines. Workers' compensation and no-fault carriers often pay by check or under their own payer ID, so those payments post against the injury case and claim number. When a line pays short of the expected rate, it goes to an underpayment queue instead of being written off.

Why Is Payment Posting Different in Orthopedics?

Orthopedic remits carry a lot of adjustment logic. Surgery is paid under multiple-procedure rules, so the highest-valued procedure is paid in full and each added procedure is reduced. Bilateral cases may be paid under modifier 50 or as RT and LT lines, and payers do not agree on which. A poster who keys only the check total cannot tell whether a reduction landed on the right line. Each line has to be compared with what the fee schedule and the global surgical package allow.

The payer mix adds a second layer. Health plans send 835 files, but many workers' compensation carriers and auto insurers still pay by check with a paper explanation of review. They pay from state fee schedules, not the Medicare rate. One injury can involve both a carrier and a health plan. Posting a carrier check to the wrong guarantor leaves balances that AR management staff later chase on the wrong account.

Drugs and supplies complete the picture. In-office injections are paid by HCPCS unit, braces and walking boots are paid under DMEPOS rules, and some commercial ASC contracts pay implants at invoice cost. Each pays on a different basis, so one expected-payment check does not fit them all. Denials found while posting also need to move straight to denial management rather than sit in the ledger as zero-pay lines.

What Orthopedics Payment Posting Software Handles

CARC 59 multiple-procedure reduction

Each reduced line is compared with the expected amount for its rank in the case, so a reduction applied to the primary procedure instead of the secondary one is flagged. (X12 Claim Adjustment Reason Codes)

CARC 97 on global-period visits

Visits denied as included in the surgical package are matched to the surgery date and its global days, and the poster sees whether the claim carried modifier 24, 78 or 79. (CMS MLN Global Surgery Booklet)

Modifier 51 and 50 payment rules

Bilateral and multiple-procedure lines are checked against the Medicare payment indicators for each CPT code, so a bilateral knee procedure paid as one side is caught at posting. (Medicare Claims Processing Manual, Chapter 12: Physicians/Nonphysician Practitioners)

Workers' compensation fee schedules

Carrier payments post against the claim number and are compared with the state fee schedule, such as the California Official Medical Fee Schedule, rather than a health plan rate. (California Division of Workers' Compensation, Official Medical Fee Schedule)

835 PLB provider-level adjustments

Takebacks and offsets reported in the PLB segment post as their own lines and link to the original claim, so a recoupment on one patient is not hidden inside another patient's payment. (X12 transaction sets, including the 835 Health Care Claim Payment/Advice)

Hyaluronic acid units (J7321 to J7329)

Injection payments are checked per HCPCS unit. Some of these codes are billed per dose and others per milligram, so a short payment on a per-milligram product is easy to see. (UnitedHealthcare medical benefit drug policy: Sodium Hyaluronate)

How Does Orthopedics Payment Posting Software Work?

1. 1. Import the 835

   The system pulls each ERA from the clearinghouse and balances it to the payment total. Files that do not balance stop before anything posts.

2. 2. Match lines to charges

   Each service line is matched to the CPT code, modifiers and units billed. Surgical lines keep their order, so the reduction can be compared with the expected rank.

3. 3. Check the expected payment

   Allowed amounts are compared with the contract or fee schedule for that payer and site of service. Lines that pay short go to an underpayment queue with the reason code attached.

4. 4. Post carrier and attorney checks

   Workers' compensation, auto and attorney checks are posted against the injury case and claim number. The explanation of review is stored with the payment for later appeals.

5. 5. Reconcile the deposit

   Posted totals are matched to bank deposits and lockbox files using the EFT trace number. Gaps between cash received and cash posted show up on the day they occur.

6. 6. Route the exceptions

   Zero-pay lines with codes such as CARC 97, 16 or 50 move to the right work queue. The poster does not have to decide who owns each one.

Orthopedics Payment Posting Software vs. Generic Software

Who Uses It in a Orthopedics Practice

• Payment poster: A queue of only the exceptions, such as unbalanced files, short pays and paper carrier payments, with the remittance detail on one screen.
• Billing manager: Underpayment and denial counts by payer and CPT code, so a payer that keeps reducing the wrong line can be raised with its provider representative.
• Practice administrator or CFO: Cash that agrees with the bank, with contractual adjustments and takebacks posted to the general ledger instead of buried in totals.