Orthopedic Revenue Cycle Automation
Orthopedic revenue cycle management involves complex prior authorization requirements for surgical procedures, global period billing management, modifier 25/59 application for same-day procedures, and implant documentation for surgical cases. Sarva automates PA submissions for orthopedic procedures, validates global period billing rules, and applies specialty-specific claim scrubbing.
Specialty-Specific RCM Challenges
Surgical Prior Authorization
Joint replacements, spine surgeries, and sports medicine procedures require PA. Manual submission delays surgeries and frustrates patients.
Global Period Management
Orthopedic procedures have global periods (0, 10, 90 days) during which follow-up care is included. Billing separate services during global periods risks denials.
Implant Documentation
Surgical implants must be documented and billed correctly. Missing implant documentation causes claim denials and revenue loss.
Modifier Complexity
Modifier 25 for same-day E/M with procedures and modifier 59 for distinct procedural services are frequently used and frequently denied.
Authorization Issues
Orthopedic procedures frequently require prior authorization, particularly for high-cost surgeries like joint replacement and spinal fusion. Sarva maintains orthopedic-specific PA requirements by payer, auto-generates submission packages with clinical documentation, and tracks approval status to prevent surgery delays.
Common Denial Categories
Workflow Example
A patient is scheduled for knee replacement. Sarva identifies the procedure requires PA, auto-generates the submission with clinical documentation supporting medical necessity, and tracks approval status. The surgery is scheduled only after authorization is confirmed. Post-surgery, Sarva manages the 90-day global period, flagging any separately billable services for appropriate modifier use.
KPI Focus
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Frequently Asked Questions
Sarva tracks global periods for each surgical procedure and flags services billed during the global period. It identifies when modifier 25 or 59 is appropriate for separately billable services and validates that the documentation supports separate billing.
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