Pre and Post‑Operative Denials in Podiatry: What No One Tells You

Denials in medical billing are a yardstick that measures the performance of the revenue cycle of a healthcare facility. Podiatry practices, on average, face 30% more denials than any other specialty, making life hard for their billing team. The majority of these claim denials are due to pre- and post-operative care. A big chunk of the provider’s earnings is lost due to invalid coding, modifiers, or missing ABNs, etc.

In this blog, we will address steps that may help you in preventing Medicare podiatry denials. This guide includes some of the best techniques for improving the claim’s first pass rate. You will also be able to make strategies to prevent pre- and post‑operative denials in podiatry without much effort. Without further ado, let’s discuss this in detail.

Understanding Pre‑Operative Denials

Pre‑operative denials in podiatry are claims that contain the CPT codes for evaluation, management, diagnostic tests, and routine foot care checks. These steps are performed right before the operation or a few days before the operation is planned. Many of the standard checks are allowed by Medicare and commercial insurers, and some of them may require prior approval from the payers.

Reasons for Preoperative Podiatry Billing Denials

Many factors may lead your practice to receive preoperative denials, including:

Missing or Misused Modifier 57

Missing or misused Modifier 57 (Decision for Surgery) may lead payers to believe the procedure is either unnecessary or performed without prior authorization. 

Failure to Document “Medical Necessity” for Surgery

Many podiatrist fails to document or provide proof that conservative treatments (e.g., orthotics, injections, physical therapy, or NSAIDs) were tried and failed. Insurance companies may think the procedure is not a medical necessity.

Quick Comparison Table: Pre-Op Modifiers

Understanding Post‑Operative Denials

Post-operative denials are the ones podiatry practices face for the rendered services after the operation has been performed on the patient. These post-operative services can include X-ray, CT scan, MRI, blood test, as well as a second procedure. In post-operative denials, Medicare or other commercial payers think the procedure is already covered under the first procedure billing. These denials are high-dollar claims and may cause over 50% of the revenue to be lost for the entire treatment period.    

Common Causes of Post-Op Denials in Podiatry

Some of the common post-operative podiatry insurance claim denials are:

Complications vs. New Problems

If a patient has suffered from any type of fracture after the operation, the second procedure may not be covered under the same CPT codes. Whereas post-operative complications are bundled and treated under the same procedures. Adding services to new treatments to the previous one will initiate an automatic denial. 

Unrelated Issues

If a patient, after having a bunionectomy, comes for the treatment of stomach issues or gastritis, this will not be in the bundled services. The provider can add a modifier for the medical condition and treat the patient appropriately. Post-operative unrelated medical conditions cannot be bundled into one claim.   

Post-operative Modifiers to Prevent Denials

Why Surgical Denials Have High Cost

Preventing podiatry billing errors is of utmost importance for foot care hospitals. The majority of podiatry reimbursement claims for post- and pre-operative surgeries cost more than $1500. Even a few claims of the same worth can cause revenue leakage, leading to poor financial health of your podiatry clinic. 

Additionally, post-operative care is more complicated and can take more time for physicians, and in case reimbursement is denied, it adds more frustration. Podiatry surgeons spend on average 30 minutes to 3+ hours in the operating room. After that much time, if the claim is denied, it not only increases the financial burden on clinics but also results in delayed payments to nursing and other staff. Thus, the total cost per denied claim is way higher than the reimbursement amount that a provider may get after submission. 

Best Practices for Prevention

After understanding the effects of pre- and post-operative podiatry billing and its cost for healthcare practices, let’s go through what steps you can take to minimize the claim denials on surgical procedures.   

Accurate Coding & Modifier Use

Podiatry coders should use accurate coding for updated routine foot care coverage as suggested by Medicare. Latest ICD-10, CPT, and HCPCS codes increase first pass rate, resulting in hurdle-free reimbursement.

Thorough Documentation

Podiatry documentation requirements are complex. RCM staff must ensure that to obtain all documents before claim submission. They can also take medical necessity documentation to justify the reasons for rendered services to strengthen accuracy and compliance. 

Understand Global Surgical Package Rules

Our podiatry compliance tips include training and understanding the global period surgical package rules. Medical billers can ask insurers for the allowed window of time during which claims can be submitted, bundled into a single claim.   

Pre-Authorization & Eligibility Checks

One of the best practices to deter claim denials is to regularly check for prior authorization and eligibility verification. The medical billing team can obtain details like co-pays, deductibles, co-insurance, validity, and out-of-pocket expenses. This way, billers can create a prevention strategy.  

Issue an Advance Beneficiary Notice (ABN)

Providers must issue an advance Beneficiary Notice (ABN) in podiatry procedures where it’s possible that Medicare or private insurers can deny the claim. By doing this, accurate financial responsibility can be delegated to patients for rendered care. 

Sum-up

Controlling pre- and post-operative claim denials is the backbone of a healthy revenue cycle. The responsibility does not lie upon podiatrists alone, but medical billers as well are equal partners in helping grow a medical practice. Healthcare institutions can take various steps, like understanding the nuances of pre- and post-operative billing. By making insurance eligibility checks, pre-authorization, using accurate diagnostic codes, and issuing ABNs, podiatry physicians can reduce denials by more than 50%.

In any case where you’re running short of trained podiatry billing staff, billingpodiatry is your best bet for timely reimbursements. Contact us for tailored solutions to permanently block the denials.

FAQs

Why are pre- and post-operative podiatry claims often denied?

The main reasons for a podiatry practice to get claim denials on post- and pre-operative claims are due to incorrect coding and billing. The other reasons include that some insurers add both post- and pre-procedure services bundle into a global surgical package. Lastly, if a provider does not issue ABNs for frequency visits and procedures, the claim is denied, and financial responsibility falls on the practice.  

How can podiatry practices prevent claim denials for these procedures?

Providers can prevent claim denials by addressing podiatry claim denial reasons with the following practices:

• Accurate coding with proper CPT/ICD codes and modifiers.
• Thorough documentation of pre-op risk assessments and post-op care.
• Verification of medical necessity, especially linking foot care to systemic conditions like diabetes.
• Understanding payer rules about global periods and bundled services.
• Pre-authorization for surgical procedures when it’s required.    

Can post-operative complications be billed separately?

Yes, providers can bill patients for post-operative infection that may develop after 3-4 weeks. Additionally, unrelated medical issues are also billed separately by the practices.