Year-end A/R review should not mean simply working the oldest claims first. For an orthopedic practice, a 90- or 120-day-old claim may still be highly recoverable, while a newer claim can already be at risk because of a filing deadline, missing documentation, an authorization problem, or an unresolved payer issue.
That is why your year-end orthopedic A/R review should answer four questions:
What should we recover? What should we correct? What should we appeal? And what should we close?
A disciplined review can help you protect collectible revenue, reduce unnecessary write-offs, and enter the new year with a cleaner A/R.
Why Orthopedic A/R Requires a Different Year-End Review
Orthopedic practices frequently manage high-value surgical claims, postoperative services, injections, imaging, implants, durable medical equipment, workers’ compensation claims, and multiple payer requirements. These complexities can make it difficult to identify where revenue is being delayed or lost.
That is where Orthopedic A/R Audit Services can help. A focused A/R audit can identify aging high-value claims, denial patterns, underpayments, coding issues, documentation gaps, and other revenue risks before they turn into unnecessary write-offs.
Common problems include:
- Global surgery payment issues
- Incorrect or unsupported modifiers
- NCCI-related claim edits
- Missing operative or clinical documentation
- Prior authorization discrepancies
- Medical-necessity denials
- Underpayments against contracted rates
- Workers’ compensation or auto claims
- Unbilled or incorrectly billed secondary insurance
- Claims approaching payer-specific filing or appeal deadlines
CMS states that Medicare payment for most surgical procedures includes services furnished during a 10- or 90-day global period, depending on the procedure. That makes accurate identification of services inside and outside the global package particularly important when reviewing orthopedic surgical A/R.
A comprehensive Orthopedic A/R Audit can help your practice determine which claims should be recovered, corrected, appealed, escalated or closed, giving your team a clearer path to year-end revenue recovery.
Age Is Not the Same as Priority
A common year-end mistake is sorting an A/R report only by aging.
Instead, evaluate each significant claim using five factors:
| Factor | Question to Ask |
|---|---|
| Age | How long has the claim been outstanding? |
| Balance | How much collectible revenue is at stake? |
| Deadline | Is there a timely-filing or appeal deadline approaching? |
| Root cause | Why has the claim not been paid? |
| Documentation | Do you have the records needed to correct or appeal it? |
This creates a more useful orthopedic A/R recovery priority.
For example, a $25,000 surgical claim at 75 days with a clear denial and complete documentation may deserve more immediate attention than a $300 claim that has simply been pending for 110 days.
A Practical Year-End Priority System
Priority 1 — Recover Now
Work high-dollar claims with a clear path to payment, especially when a filing or appeal deadline is approaching.
Priority 2 — Appeal or Reconsider
Claims denied for medical necessity, coding, authorization, documentation, or payer processing issues should be reviewed to determine whether an appeal or reconsideration is appropriate.
Priority 3 — Correct and Resubmit
If the problem is a correctable coding, demographic, modifier, claim-format, or documentation issue, fix the underlying problem rather than repeatedly calling the payer.
Priority 4 — Investigate
Pending, suspended, or apparently processed claims need a documented next action. “Follow up later” is not an A/R strategy.
Priority 5 — Close With Documentation
A claim should not be written off simply because it is old. First determine whether additional recovery action is commercially and administratively reasonable and document the reason for closure.
1. Find High-Dollar Claims Before They Become Year-End Write-Offs
Start your review with the highest outstanding balances.
For orthopedic practices, this may include:
- Joint replacement procedures
- Spine procedures
- Fracture and trauma services
- Arthroscopic procedures
- Implant-related charges
- High-value injections
- Workers’ compensation claims
- Auto accident claims
- Hospital or ASC-related professional claims
Do not assume every unpaid high-dollar claim is a denial. Separate your A/R into denied, pending, underpaid, unbilled, suspended, secondary-pending, and filing-risk categories. Each category requires a different action. An underpaid claim, for example, should generally be investigated against the applicable contract or fee schedule rather than treated like a standard denial.
2. Review Global Surgery and Modifier-Related A/R
Global surgery issues can create recurring problems in orthopedic billing. CMS identifies 10-day and 90-day global periods for applicable surgical procedures.
During your year-end review, examine claims involving:
- Postoperative E/M services
- Staged procedures
- Unplanned returns to the operating room
- Unrelated procedures during a postoperative period
- Separately identifiable E/M services
- Multiple procedures performed during the same encounter
But do not add a modifier simply to bypass an edit.
CMS specifically notes that modifier 59 is often used incorrectly and should be supported by the circumstances of the service. The same principle applies to modifier 25. Documentation must support a significant, separately identifiable E/M service when required. Your billing team should therefore review the clinical documentation, procedure relationship, global-period status and payer/NCCI rules together.
3. Separate Coding Problems From Documentation Problems
A denial that looks like a coding issue may actually be a documentation issue.
For every significant orthopedic denial, ask:
- Was the procedure coded correctly?
- Does the diagnosis support the service?
- Are laterality and anatomical details documented?
- Are the units correct?
- Is the modifier supported?
- Was authorization obtained when required?
- Does the operative report support the billed service?
- Does the payer have specific documentation requirements?
CMS maintains NCCI policies and updates its Medicare NCCI Policy Manual as part of its coding-edit guidance. Simply changing a modifier and resubmitting the same claim can create another denial.
4. Protect Claims With Filing and Appeal Deadlines
One of the most important year-end A/R questions is:
How much time is actually left to recover this claim?
For Original Medicare fee-for-service claims, federal regulations generally require claims to be filed within one calendar year from the date of service, subject to applicable exceptions.
That is different from the deadline for appealing a Medicare claim determination. For a Medicare redetermination, the first level of appeal, CMS generally gives the appellant 120 days from receipt of the initial claim determination to file the request. If the redetermination is unfavorable, the next-level reconsideration generally has a 180-day filing period from receipt of the redetermination decision.
These are separate clocks.
Your A/R team should track:
Date of service → claim submission → payer response → denial date → appeal deadline → next action.
Do not apply Medicare deadlines automatically to commercial, Medicare Advantage, workers’ compensation, or other payer claims. Their requirements can differ by payer, contract, state, or claim type.
5. Look Beyond Denials: Find Underpayments
A clean-claim rate does not tell you whether every correctly processed claim was paid correctly.
Year-end A/R review should also identify:
- Contractual underpayments
- Incorrect allowed amounts
- Missing reimbursement for separately payable services
- Incorrect patient responsibility
- Secondary claims that were never submitted
- Unresolved recoupments
- Payment discrepancies involving high-value services
For high-dollar orthopedic claims, compare the payer’s payment against the applicable contract or reimbursement methodology. A claim marked “paid” is not necessarily a claim that was paid correctly. That distinction can uncover revenue that a conventional denial report never shows.
6. Give Workers’ Compensation and Liability Claims Their Own Worklist
Workers’ compensation and auto/liability claims can remain open for different reasons than standard commercial insurance claims.
Before year-end, identify claims waiting on:
- Claim numbers
- Adjuster information
- Attorney or lien information
- Medical documentation
- Authorization
- Accident-related records
- Payer/liability determination
- Coordination with secondary coverage
Do not allow these claims to sit indefinitely in a generic “pending” bucket. Assign an owner, document the next action, and establish a follow-up date.
7. Build a Year-End Orthopedic A/R Decision Report
Your final A/R report should be more useful than an aging summary.
At minimum, track:
- Total A/R
- A/R over 60 days
- A/R over 90 days
- A/R over 120 days
- High-dollar outstanding claims
- Denial volume and value
- Underpayment volume and value
- Appeals pending
- Claims approaching filing deadlines
- Workers’ compensation/liability A/R
- Unbilled or secondary-payer A/R
- Recovery dollars
- Write-offs by reason
Then classify every material account:
Recover → Correct → Appeal → Escalate → Close
That gives practice leadership a clear picture of where money is stuck and what the medical billing team is doing about it.
What Should You Close Before Year-End?
The goal is not to make the A/R report look smaller.
A claim should be considered for closure only after the team has determined:
- Why it remains unpaid
- Whether additional documentation exists
- Whether correction or rebilling is possible
- Whether an appeal remains available
- Whether payer deadlines have expired
- Whether contractual or administrative adjustments apply
- Whether further collection effort is economically reasonable
- Whether the reason for closure is properly documented
A smaller A/R balance is not automatically a healthier A/R balance. A practice can reduce A/R simply by writing off unresolved claims. The better objective is to reduce unresolved, recoverable A/R.
Provider Self-Assessment: Is Your Orthopedic A/R Ready for Year-End?
Use this checklist to identify aging claims, recovery risks, billing errors, and unresolved A/R before closing the year.
| Year-End A/R Review | Status |
|---|---|
| Have you reviewed all high-dollar orthopedic claims individually? | ☐ |
| Have you separated denied, pending, underpaid, unbilled, and secondary-pending claims? | ☐ |
| Have you prioritized 90+ and 120+ day A/R based on recovery potential—not age alone? | ☐ |
| Have you identified claims approaching Medicare or payer-specific filing and appeal deadlines? | ☐ |
| Are global surgery and postoperative claims being reviewed against the applicable global-period rules? | ☐ |
| Are modifiers supported by the clinical documentation and applicable payer/NCCI requirements? | ☐ |
| Have you investigated NCCI-related denials before resubmitting claims? | ☐ |
| Have you compared high-dollar payments against contracted reimbursement or applicable fee schedules? | ☐ |
| Have workers’ compensation and auto/liability claims been assigned separate follow-up workflows? | ☐ |
| Have you reviewed unresolved claims for missing operative reports, medical records, authorization, or other documentation? | ☐ |
| Does every significant unresolved claim have a documented next action and follow-up date? | ☐ |
| Are proposed write-offs supported by a documented reason and recovery review? | ☐ |
Improve Orthopedic A/R Recovery With Health Quest Billing
A successful year-end A/R review is about more than aging balances. Identify recoverable revenue, unresolved denials, underpayments, documentation gaps, and claims at risk of timely-filing deadlines before they become write-offs.
Need help recovering orthopedic A/R? Health Quest Billing helps practices manage denials, identify underpayments, prioritize high-value claims, and strengthen A/R follow-up.
