Orthopedics Workflow Software

Workflow in a Orthopedics Practice

A single knee replacement passes through many hands. The surgical scheduler books the case. The authorization team gets approval. A financial counselor reviews the estimate with the patient. After surgery, a coder checks the operative note, the ASC billing team waits for the implant invoice, and the billing office follows the claim. Workflow software gives each step its own queue. Items arrive with the facts the person needs, such as the CPT codes, the payer, the surgery date and any notes. Each item has an owner and a due date tied to the surgery date or the filing limit. If an item sits too long, it moves to a lead. Work injury cases follow their own path, with tasks for adjuster calls and doctor's reports. Most items reach a queue after automation has done what it can, so staff spend their time on the work that needs judgment.

Why Is Workflow Different in Orthopedics?

Orthopedic work is tied to dates that cannot move. A surgery date sets the deadline for authorization and patient clearance. A global period sets which visits can be billed. A work injury case sets dates for progress reports. When work lives in email and sticky notes, these deadlines slip, and the cost shows up as a canceled case or a denied claim.

Orthopedic groups also hand work across teams more than most practices. The clinic, the ASC, imaging, therapy and the billing office often sit in different places and report to different managers. A missing implant invoice may need the ASC buyer. A prior authorization for MRI may need the clinic to send therapy notes. Workflow has to route items across teams and show who owns each one at any time.

The best queues are built on exceptions. Routine items, such as clean claims and matched remits, should never reach a person. What does reach a person should be sorted by value and deadline. That is the idea behind exception-based work management, and it lets a small team keep up with a large surgical practice. Denials that reach a queue link to denial management so the root cause gets fixed.

What Orthopedics Workflow Software Handles

Surgery authorization queue

Scheduled surgeries without a matching authorization sit in one queue, sorted by surgery date. Items near the date move to a lead. CMS-0057-F sets decision time limits for Medicare Advantage, Medicaid and some other plans, and those decisions update the item when they arrive. (CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F))

Global-period coding hold

Visits held by the global-period edit go to a coder with the surgery date and note attached. The coder adds modifier 24, 25 or 79 when supported, or releases the visit as no-charge. (CMS MLN Global Surgery Booklet)

Work injury report tasks

Each work injury case gets tasks for adjuster calls and doctor's reports, such as the PR-2 in California. Tasks are due on the dates the case requires. (California Division of Workers' Compensation forms)

DME standard written order check

Braces and boots billed to Medicare need a standard written order and supporting notes. Missing items open a task for the clinic before the claim is sent. (Medicare Program Integrity Manual, Chapter 5: DMEPOS items and services)

Denial queues by CARC code

Denials are routed by reason code. CARC 197 goes to the authorization team, CARC 4 to coding and CARC 16 to the billing office. (X12 Claim Adjustment Reason Codes)

How Does Orthopedics Workflow Software Work?

1. 1. Create the item

   An item opens when automation finds something it cannot settle, or when a person adds a task. It carries the patient, case, payer and reason.

2. 2. Route to an owner

   Rules send the item to the right team and person. Routing follows the item type, site, payer or surgeon.

3. 3. Set the due date

   Each item gets a due date tied to its deadline, such as the surgery date or the filing limit. The queue sorts on that date and on value.

4. 4. Work and hand off

   The owner works the item and adds notes. If another team is needed, the item is handed off with the history attached.

5. 5. Escalate when stuck

   Items past due move to a lead. Leads see every stuck item across teams on one screen.

6. 6. Close and learn

   Closed items record how they were resolved. Repeat causes are sent back so the rule or process can be fixed.

Orthopedics Workflow Software vs. Generic Software

Who Uses It in a Orthopedics Practice

• Surgery scheduler: A clear view of which booked cases still need authorization, clearance or an implant order, sorted by surgery date.
• Billing supervisor: Every queue and owner on one screen, with past-due items flagged and a record of each handoff.
• Practice administrator: Workload by team and site, so staff can be moved to the queues that are falling behind.