5 orthopedic billing and RCM strategies to improve revenue

From documentation to claim submission: Practical strategies to improve revenue capture for orthopedic and pain management practices

Orthopedic and pain practices manage some of the most complex revenue cycles in healthcare. Even small workflow breakdowns—like a missed injection charge, incomplete documentation, or an unresolved eligibility issue—can delay or reduce payment for valuable encounters. As practices add providers and locations, gaps between documentation, authorizations, charge capture, and billing can create more rework and less predictable cash flow.

Practices can address these challenges by treating billing as an integrated workflow rather than fixing individual processes in isolation. This involves implementing key strategies to help strengthen documentation, accelerate claim submission, verify insurance eligibility, and identify denial patterns that lead to leakage.

This guide outlines five operational improvements practices can begin implementing to improve orthopedic revenue cycle management, reduce manual work, and help collect more of what they’re owed.

Top orthopedic revenue cycle management challenges

Revenue cycle management can be particularly challenging for orthopedic and pain management practices because procedural billing often involves complex documentation requirements and evolving payer rules.

Specific obstacles throughout their revenue cycle include:

• Changing payer and coverage requirements: Practices must stay up to date with local and payer-specific coverage rules, prior authorization requirements, and medical necessity criteria.
• Coding and documentation complexity: Many procedures require detailed documentation, coding modifiers, imaging guidance, and compliance with global surgery rules.
• Workflow fragmentation: Practices must seamlessly coordinate administrative processes—including charge capture, claims management, eligibility, patient payments, and reporting—across often-disconnected platforms and sites of care.
• Limited visibility: Without comprehensive, real-time reporting, practices may struggle to identify whether recurring delays and denials originate with particular payers, procedures, locations, or workflow steps. This makes it difficult to improve workflows and address recurring issues impacting revenue.

5 orthopedic medical billing strategies to improve RCM

Below are five workflow improvements that practices can begin implementing to improve revenue capture and reduce leakage. As with any process update, it’s important to understand that results will vary depending on payer mix, current performance, staffing, strategy adoption, and implementation quality.

1. Establish pre-visit coverage and patient-responsibility workflows

The revenue cycle begins before the patient even arrives for their appointment. Practices need to confirm coverage and identify authorization requirements and, whenever possible, set expectations about patient financial responsibility before care. Difficulty navigating these steps can lead to delays in payment and billing processes.

To help streamline scheduling and reimbursement workflows, practices can set up pre-visit workflows that include the following steps:

Select the correct insurance package

Accurate insurance selection helps ensure claims are routed to the right payer. Automated tools can analyze patient insurance cards and recommend the correct insurance package, saving time on manual entry and reducing denials. Practices using Automated Insurance Selection, for example, saw a 15.6% reduction in patient insurance-related claim denials compared with customers using manual insurance-selection methods.¹

Confirm active eligibility

Use automated tools to verify insurance eligibility before the patient’s visit. This allows practices to catch any eligibility issues early and avoid delays in care or reimbursement.

Determine benefits and prior authorization requirements

Many orthopedic and pain management services, such as MRIs, CT scans, and joint injections, as well as planned procedures, require prior authorization. But the authorization process can take a substantial amount of staff time and effort when managed manually. To help, athenaOne®’s Express Authorizations solution helps identify when prior authorization may be required and expedites submission for select payers.

Estimate the patient's copay

Set expectations by calculating patient copay before each appointment. AI-powered Copay Prediction, for instance, helped practices increase accuracy for non-zero copays by 39 percentage points compared with prior estimation solutions.² By understanding their financial responsibility up front, patients can be better prepared to pay at the right time.

Outline the patient's broader financial responsibility

Beyond copays, patients may be responsible for deductibles, coinsurance, or other out-of-pocket costs. Surface these obligations ahead of time to reduce roadblocks in the billing process and avoid confusing or frustrating patients with unexpected costs.

Communicate and collect the appropriate amount

Once patients clearly understand their eligibility, requirements, and responsibilities, practices can request payment and begin to close the billing cycle.

2. Automate charge capture for injections and procedures

Orthopedic and pain management practices consistently capture charges for a high volume of complex procedures, from image-guided services to injections and nerve blocks. Missed or incomplete charges can delay payments and claim submissions.

One solution is to automate this process to reduce charge-entry lag and improve accuracy. Instead of relying on manual charge capture, orthopedic practices can use automated tools that quickly and efficiently capture procedure charges and move encounters toward claim creation. athenaOne’s Automatic Claim Creation feature, for example, automates procedure charge capture, helping to improve cash flow while also reducing time-consuming administrative tasks. Across athenaOne customers, those using Automatic Claim Creation created claims nearly four days faster than customers not using the solution (2.43 days vs. 6.41 days).³

It’s important to remember that charge-entry lag can also be affected by clinician behavior, including whether the encounter is closed promptly. Automatic Claim Creation is most effective when paired with streamlined and efficient workflows.

3. Build documentation and coding support into complex encounters

Incomplete documentation or coding errors can delay claims and contribute to denials. This is a particular challenge for orthopedic practices, which often manage complex encounters involving multi-area examinations and postoperative care.

Instead of relying primarily on downstream correction, practices can build coding and documentation support directly into clinical and billing workflows. This can help identify those issues earlier, before they delay claim submission or contribute to denials. Practices can use AI-powered note generation tools to listen to encounters and automatically generate summaries for clinicians to review and add to patient records.

Practices with limited internal coding capacity might opt for Medical Coding support, which allows them to hand over coding work to an athenahealth-vetted team of trained coding experts.

Once documentation and coding are complete, claim scrubbing and claim alarms can provide an additional quality-control layer by proactively identifying potential issues before or after claims are submitted. This allows staff to focus attention on claims that require review rather than treating every claim as an exception.

4. Conduct denial analysis by payer and procedure

Denials consume staff time, delay payment, and can reveal recurring weaknesses elsewhere in the revenue cycle. According to a 2024 survey by Premier, almost 15% of reimbursement claims submitted to payers were initially denied, costing providers about $19.7 billion a year in efforts disputing denials.⁴ Understanding the common causes can help practices reduce recurring denials.

Beyond just tracking denial volume, practices should analyze denials by factors such as payer, procedure, location, and reason for denial to help identify recurring issues and optimize their processes accordingly. For multisite organizations, comparing these patterns across locations can also help leaders identify operational variation and determine where standardized workflows or additional support may be necessary. For example, a spike in denials may stem from coding modifiers for a specific procedure or a certain payer’s stringent documentation requirements.

Billing insight dashboards and workflow analytics can help surface these issues so teams can take steps to reduce orthopedic claim denials. For instance, athenaOne’s AI-powered denials advice capabilities led to a 30% increase in payment recovery for coding-related denials compared with manual rework alone.⁵ athenaOne also offers Enhanced Claim Resolution services to analyze, address, and rework complex denials on behalf of your organization, so staff can stay focused on the patient experience.

5. Set targets for timely encounter note closure

Completed encounter notes support downstream coding and claim workflows. Delaying this task—because of administrative overload or slow manual systems—can lead to bottlenecks in claims processing, coding review, and cash flow.

Practices can establish clear targets for closing encounter notes promptly to support faster downstream coding and claim workflows. Real-time reporting tools also offer visibility into financial activity and key RCM metrics like collections posted, total relative value units (RVUs) per visit, and schedule utilization. These metrics can help teams identify opportunities to improve patient experience and billing workflows.

For multisite practices, consistent reporting can help leaders compare performance across locations and identify workflow problems that may otherwise remain hidden. They can use these insights to prioritize operational improvements, replicate successful workflows, and allocate resources where they are needed most.

Connect billing functions across the patient lifecycle

Improving orthopedic RCM is possible, but it’s not as simple as updating a reporting system or using a new claims process. Ultimately, revenue improvement depends on optimizing and integrating processes across your entire workflow.  

Across the patient lifecycle, these workflows should work together to:

5. Confirm coverage, authorization requirements, and known patient responsibility.
6. Capture the service accurately.
7. Complete documentation promptly.
8. Validate coding and claim readiness.
9. Analyze claim and payment outcomes and feed findings back into upstream workflows.

For example, Orthopedic + Fracture Specialists reduced its reliance on third-party applications by 75% after implementing athenaOne—illustrating how a connected platform can simplify the technology environment supporting a complex orthopedic practice.

By taking this holistic approach to revenue cycle management, practices can be better prepared to improve visibility, reduce preventable delays, and strengthen revenue capture over time.

Learn more about how athenaOne helps connect clinical documentation, coding, charge capture, claims, denial management, patient payment, and reporting across your revenue cycle.