Orthopedic Billing and Coding Guide: Global Periods, Modifiers, Fracture Care, and Denial Prevention

This guide explains the practical billing workflow for U.S. orthopedic practices, sports medicine groups, hand and foot and ankle specialists, spine practices, orthopedic ambulatory surgery centers, and the medical billing companies that support them. It covers office visits, the global surgical package, modifiers, fracture care, casting, injections, imaging, surgical payment rules, durable medical equipment, prior authorization, workers' compensation, denials, and accounts receivable follow-up. Use it as an operational billing guide, not legal, clinical, reimbursement, or coding advice. CPT, HCPCS, Medicare, Medicaid, commercial payer, workers' compensation, and state requirements change. Always verify the current AMA CPT manual, HCPCS updates, Medicare Administrative Contractor policies, payer medical policies, NCCI edits, provider contracts, authorization terms, and state requirements before submitting claims.

What Is Orthopedic Billing?

Orthopedic billing is the process of documenting, coding, submitting, and following up on services used to evaluate and treat conditions of the musculoskeletal system. It spans conservative care, procedural care, and surgery, often for the same patient in the same episode.

An orthopedic practice may bill or coordinate billing for:

• New and established patient office visits
• Consultations, where the payer still recognizes them
• In-office radiographs and, in some groups, advanced imaging
• Fracture and dislocation care
• Cast, splint, and strapping application
• Joint, bursa, and soft tissue injections
• Viscosupplementation and other injectable drugs
• Trigger point and tendon sheath injections
• Arthroscopic and open surgery in a hospital or ASC
• Office-based procedures
• Postoperative care inside and outside the global period
• Durable medical equipment, braces, and orthotics
• In-house physical or occupational therapy
• Workers' compensation and personal injury care
• Independent medical examinations and impairment ratings

Very few specialties touch this many distinct payment systems. A single knee patient can generate a physician fee schedule claim, a radiology component claim, a DMEPOS claim, a therapy claim, and a facility claim, each governed by different rules.

Why Orthopedic Billing Is Different

Orthopedic claims fail for structural reasons more often than for coding ignorance. The most common structural pressures are:

1. The Global Surgical Package Governs the Calendar

Once a procedure with a 10 or 90 day global period is billed, every subsequent encounter for that patient must be evaluated against the global period before it is billed. Practices that do not track global periods either write off payable visits or bill visits that are not payable. Both are expensive.

2. Anatomy Is Part of the Claim

Side, joint, digit, and level are not descriptive detail in orthopedics. They are adjudication data. The diagnosis, the procedure code, the modifier, and the operative note all have to agree.

3. One Episode Crosses Multiple Fee Schedules

The professional service, the technical component of imaging, the brace, the therapy, and the facility charge are priced under different systems with different rules for authorization, medical necessity, and appeal.

4. Prior Authorization Sits on the Critical Path

Advanced imaging, surgery, injections, and DME all commonly require authorization. In orthopedics the authorization frequently has to be obtained between the office visit and a procedure scheduled days later, which puts the billing team on a clinical timeline.

5. A Meaningful Share of Volume Is Not Health Insurance

Workers' compensation, auto and personal injury, and liens follow their own rules, fee schedules, forms, and timelines. Running them through the commercial workflow produces silent aging.

Orthopedic billing therefore requires episode-level control, not claim-level data entry.

The Orthopedic Revenue Cycle

A well-controlled orthopedic revenue cycle usually follows these stages.

1. Referral and Intake

The practice collects:

• Patient demographics and coordination of benefits
• Insurance information and any secondary coverage
• Referring provider information
• Referral or order, when required
• Mechanism and date of injury
• Whether the injury is work related, auto related, or neither
• Employer, claim number, and adjuster for work injuries
• Attorney and letter of protection details for liens
• Prior imaging, prior surgery, and prior conservative care
• Current braces, devices, or therapy

Case type has to be identified at intake. A work injury discovered at the time of billing has already been scheduled, treated, and documented under the wrong rules.

2. Eligibility and Benefits Verification

The front-end team verifies:

• Active coverage and network status
• Specialist copayment, deductible, and coinsurance
• Referral requirement
• Prior authorization requirement by service type
• Advanced imaging benefit and any radiology benefit manager
• Surgical benefit and site-of-service restrictions
• DME benefit, deductible, and preferred supplier requirements
• Therapy benefit and visit limits
• Injection and viscosupplementation coverage criteria
• Facility network status for the planned ASC or hospital

A patient can be in network with the surgeon and out of network with the facility, the imaging center, or the DME supplier. Structured eligibility and benefits verification should check the whole episode, not just the visit.

3. Visit, Documentation, and Coding

The clinician documents history, examination, imaging findings, diagnosis with laterality, conservative care attempted, and the plan. The coding team confirms that the documentation supports the level of service, any same-day procedure, and the medical necessity the payer requires.

4. Authorization and Scheduling

The authorization record should identify:

• Approved CPT or HCPCS codes
• Approved site of service and facility
• Approved rendering provider
• Approved units, visits, or quantity
• Approved diagnosis
• Authorization number and effective date range
• Expiration date
• Any prerequisite conservative care documentation

Surgery should not be scheduled until the team knows what was approved, at which facility, and for how long the approval is valid. Prior authorization support works best when it is a tracked queue with owners and due dates rather than an ad hoc task.

5. Charge Capture

Charge capture in orthopedics has two failure points: the office and the operating room. Office charges leak through unbilled injections, unbilled supplies, and undocumented casting. Surgical charges leak through delayed operative notes, missing assistant surgeon claims, and procedures performed but not coded from the note.

6. Claim Scrubbing and Submission

Before release, the claim should pass laterality, modifier, global period, NCCI, MUE, authorization, and place-of-service checks.

7. Payment Posting and Reconciliation

Orthopedic contracts contain multiple procedure reductions, bilateral adjustments, assistant surgeon percentages, and implant or supply carve-outs. Posting has to compare the paid amount to the expected contract amount, not simply record what arrived. See payment posting for how this is staffed.

8. Denial Management and AR Follow-Up

Denials should be worked by root cause and fed back into the front end. Denial management and AR follow-up in orthopedics are heavily documentation-driven, and many appeals require the operative note, the authorization record, or both.

Office Visits and E/M Coding

Most orthopedic encounters are still office or outpatient evaluation and management visits.

Level selection is based on medical decision making or on total time on the date of the encounter. In orthopedics, the decision-making path is usually stronger than the time path because the visit involves image review, an established diagnosis, and management decisions with procedural risk.

Practical E/M Points for Orthopedics

• Independent interpretation of imaging can support decision making, but not when the practice is also billing the professional component of that same study. Choose one, and document accordingly.
• Conservative care history matters. Payers frequently require documented failure of conservative treatment before approving injections, advanced imaging, or surgery, and that history lives in the E/M note.
• Medicare's complexity add-on G2211 is intended for visits that serve as a continuing focal point for care or as ongoing care of a single serious condition. Its fit with episodic orthopedic care is limited. Do not append it by default.
• Code 99024 exists so that postoperative visits inside a global period can be tracked. Some Medicare contractors and payers require it. Reporting it also gives the practice real data on how much postoperative work the global payment is absorbing.

The Global Surgical Package

The global surgical package is the single most important concept in orthopedic billing. It defines what is already paid for and what can still be billed.

Under Medicare, the global package for a major surgery generally includes the preoperative visit on the day of or the day before the procedure, the procedure itself, and typical postoperative care during the global period, including complications that do not require a return to the operating room. Commercial payers commonly follow a similar structure but not always identical rules.

What Is Generally Included

• The preoperative visit within the defined window
• The operation itself
• Local anesthesia, digital block, or topical anesthesia
• Immediate postoperative care and order writing
• Evaluating the patient in the recovery area
• Typical postoperative visits related to recovery
• Dressing changes and routine wound care
• Removal of sutures, staples, wires, drains, and casts
• Management of complications not requiring a return to the operating room, under Medicare rules

What Is Generally Not Included

• The initial consultation or visit at which the decision for major surgery was made
• Services of another physician, unless under a transfer of care
• Visits unrelated to the diagnosis for which surgery was performed
• Treatment of the underlying condition that is not part of recovery
• Diagnostic tests and procedures, including radiographs
• Distinct surgical procedures during the postoperative period
• A more extensive procedure when a less extensive one fails
• Return trips to the operating room for related complications
• Immunosuppressive therapy for organ transplants
• Critical care unrelated to the surgery, when criteria are met

Operationalizing the Global Period

Knowing the rule is not the same as running it. Practices that control global periods generally do four things:

1. Store the global period on the procedure at the time of surgical charge entry, not at the time of the follow-up visit.
2. Make the global end date visible in the schedule so front desk and clinical staff can see it when the patient returns.
3. Route every encounter that falls inside an open global period to a coder before it is billed.
4. Reconcile 99024 reporting against surgical volume so unbilled postoperative work is measured rather than assumed.

CMS has continued to revisit global surgical package policy in recent rulemaking, including how postoperative care is reported and paid when it is furnished by a practitioner other than the surgeon. Verify the current physician fee schedule final rule and your contractor's guidance rather than relying on prior-year practice.

Global Period Modifiers

These modifiers are the mechanism by which legitimate work inside a global period gets paid. Applying them correctly is the highest-value coding skill in an orthopedic billing team.

Choosing Between 58, 78, and 79

Three questions resolve most cases:

1. Was the second procedure related to the first? If no, use modifier 79.
2. If related, was it planned, staged, or a more extensive version of the original? If yes, use modifier 58.
3. If related and unplanned, did it require a return to the operating or procedure room? If yes, use modifier 78.

A hardware removal planned at the time of the original fixation is staged work. An unplanned washout for a postoperative infection is a return to the operating room. A contralateral knee arthroscopy six weeks later is unrelated. These distinctions change payment, so they should be documented in the operative note, not decided by the biller.

Modifier 25 Discipline

Modifier 25 is heavily audited. It is supportable when the E/M work stands on its own: a new problem, a new diagnosis, a separate body area, a change in the treatment plan, or an evaluation that led to the decision to perform the procedure. It is not supportable when the visit consists of confirming that the patient still wants the injection that was planned at the last visit. Practices with high modifier 25 rates should audit a sample before a payer does.

Fracture Care Billing

Fracture care is where orthopedic practices most often lose money quietly, because two defensible approaches exist and mixing them produces denials, refunds, or unbilled work.

Approach A: Global Fracture Care

The practice bills a fracture care code from the musculoskeletal section, such as a closed treatment code with or without manipulation. Most of these codes carry a 90 day global period.

• The initial cast or splint application is generally included.
• Cast and splint supplies are generally reported separately.
• Routine follow-up visits during the global period are not separately payable.
• Radiographs taken at follow-up visits are generally still separately payable.
• Replacement casts applied during the global period are generally separately billable.

Approach B: E/M Plus Cast or Splint Application

The practice bills an evaluation and management service plus the applicable cast, splint, or strapping application code and supplies, and does not bill a global fracture care code.

• Each medically necessary follow-up visit can be billed.
• No 90 day global period is created by the visit.
• Application codes and supplies are reported at each application when supported.

Choosing Between Them

Neither approach is automatically correct. The decision usually turns on:

• Whether the practice will actually provide the restorative care through healing, or is stabilizing before transferring the patient
• Payer policy, which sometimes prescribes one approach
• Whether the patient is likely to complete follow-up with the practice
• Whether the treatment was definitive restorative care or temporary stabilization

Practices should adopt a written policy, apply it consistently, and document the decision in the note. What cannot be done is billing global fracture care and then also billing every follow-up visit, or billing fracture care after another provider already billed it for the same episode.

Transfer of Care Modifiers

These matter constantly in orthopedics. An emergency department physician or urgent care provider who reduces a fracture and transfers the patient may bill with modifier 54. The orthopedist assuming follow-up bills the same fracture care code with modifier 55 and reports the assumed and relinquished care dates. Payment is split according to the payer's allocation. Billing the full global code when only part of the care was provided is a common and correctable error.

Casting, Splinting, and Supplies

Application codes in the 29000 to 29799 range describe the application of casts, splints, and strapping. Supplies are reported separately.

Rules That Prevent Most Casting Denials

• An application code is generally not billed when the cast or splint is applied as part of the initial fracture care or as part of a surgical procedure by the same provider.
• Cast removal by the physician who applied it is generally included in the global period rather than separately billable.
• Supply codes describe the material used. They should reflect what was actually applied, and quantity should be supported.
• Laterality modifiers belong on application codes. LT and RT are expected on extremity work.
• Document the type of device, the material, the body part, the side, and the reason. A supply charge without a documented application is indefensible.

Joint and Soft Tissue Injections

Injections are high-volume, high-denial services. Code selection depends on the anatomy and on imaging guidance, not on the drug.

Injection Billing Controls

• Never report a guidance-inclusive code such as 20611 without a permanent image and a documented report. This is a routine audit target.
• Do not separately report 76942 with an injection code that already includes ultrasound guidance.
• Trigger point codes are reported once per session based on the number of muscles injected, not once per injection.
• Bilateral and multiple joint injections require correct laterality and, in some cases, separate lines with anatomic modifiers.
• Report the drug separately with the correct HCPCS J code, the correct number of units, and the NDC when the payer requires it. Units are defined by the code descriptor, not by the vial size.
• Document and bill wastage according to payer policy, generally with the JW modifier for discarded amounts and the JZ modifier where zero drug was discarded, when the payer requires it.

Viscosupplementation

Hyaluronan and derivative products are reported with J codes in the J7318 to J7333 range. These products almost always require prior authorization and carry specific coverage criteria, commonly including documented knee osteoarthritis, radiographic evidence, failure of conservative therapy, and minimum intervals between treatment courses. Product-specific coverage varies by payer and by contractor policy, and the approved product is frequently not the product the practice stocks. Confirm the exact product, the number of injections approved, and the buy-and-bill versus specialty pharmacy pathway before the patient is scheduled.

In-Office Imaging and Components

Most orthopedic practices perform radiographs in the office. Component billing determines what can be billed and by whom.

Imaging Documentation Requirements

• The order and the medical necessity for the study, documented in the encounter note
• The number of views obtained, because radiograph codes are view-specific
• The body part and laterality
• A separate, retrievable interpretation and report when the professional component is billed
• The date and the interpreting provider

A note that states the film was reviewed is not a formal interpretation. If the practice bills the professional component, the record must contain a distinct report. If the physician instead uses the imaging review to support E/M decision making, that is a different use of the same work and both should not be claimed for the same study.

Advanced imaging adds an authorization layer. MRI, CT, and in some markets even certain radiographs run through a radiology benefit manager with its own portal, criteria, and turnaround. Build that into scheduling rather than discovering it at the appointment.

Surgical Coding and Payment Rules

Orthopedic surgical claims are rarely single-line claims. Payment depends on how the payer applies reduction and bundling rules to the combination of codes submitted.

Multiple Procedure Payment Reduction

When multiple surgical procedures are performed in the same session, payers commonly pay the highest-valued procedure at the full allowed amount and subsequent procedures at a reduced percentage. Medicare applies a standard reduction schedule to procedures with the applicable multiple procedure indicator. Contract terms differ, so the expected allowed amount should be modeled in the practice management system rather than estimated.

Bilateral Procedures

The bilateral surgery indicator on the physician fee schedule relative value file determines whether a bilateral adjustment applies at all.

Format matters as much as the indicator. Some payers want one line with modifier 50 and one unit, others want one line with two units, and others want two lines with LT and RT. Submitting the wrong format produces a partial payment that looks like a contract issue and is actually a formatting issue.

Anatomic and Laterality Modifiers

Modifier 22 for Increased Procedural Services

Modifier 22 is appropriate when the work was substantially greater than typical. It does not price automatically. To have any chance of additional payment, the claim generally needs:

• An operative note that quantifies the additional work rather than describing it as difficult
• A comparison to the typical case, such as additional operative time or unexpected findings
• A concise cover letter identifying the specific factors and the requested consideration
• A follow-up plan, because these claims pend and are frequently paid only after appeal

Unlisted Procedure Codes

Orthopedics uses unlisted codes more than most specialties. These claims require the operative note, a comparison code with a rationale for the proposed value, and manual review. They should be tracked on a separate worklist because they age differently and often require telephone follow-up rather than portal follow-up.

Implants, Supplies, and Carve-Outs

In an office or ASC setting, implant and supply reimbursement depends entirely on the contract. Some contracts carve out implants above a threshold with invoice submission; others bundle everything into the procedure rate. The billing team needs the carve-out terms in writing, and posting needs to verify that carve-outs were actually paid.

Arthroscopy and Bundling

Arthroscopy is where NCCI edits do the most damage to orthopedic revenue, in both directions: legitimate work goes unbilled, and bundled work gets billed and later recouped.

Core Principles

• A diagnostic arthroscopy is generally included in a surgical arthroscopy of the same joint and is not separately reportable.
• Multiple procedures in the same compartment are frequently bundled. Procedures in separate compartments are more often separately reportable, subject to edits and documentation.
• Some codes that were once standalone are now add-on codes and must be reported with an appropriate primary procedure. Subacromial decompression reported with rotator cuff repair is the classic example.
• Debridement performed in the same compartment as a definitive procedure is usually included.
• Converting from arthroscopic to open in the same session is generally reported with the open procedure only.

Working NCCI Edits Correctly

Every procedure-to-procedure edit carries a modifier indicator. An indicator of 0 means the edit cannot be bypassed under any circumstance. An indicator of 1 means a modifier may be used when the clinical circumstances genuinely justify it.

Modifier 59 and the more specific X modifiers, XE, XP, XS, and XU, exist to identify distinct services. XS, which identifies a separate structure, is the one that most often fits orthopedic anatomy. None of them should be appended because a line denied. The operative note has to establish the separate structure, session, or encounter first.

Medically unlikely edits also apply. An MUE caps the units of a code that will be paid on a date of service for a patient. When a legitimate case exceeds the cap, the correct path is documentation and appeal, not splitting the claim across dates.

Assistants, Co-Surgeons, and Split Care

What Gets Assistant Claims Paid

• Confirm the assistant surgery indicator for the specific code. Medicare publishes an indicator on the relative value file, and many codes do not allow an assistant at all.
• The operative note must name the assistant and describe the assistant's role. A signature block alone is not enough.
• For co-surgery under modifier 62, both surgeons report the same code with the modifier and each dictates a note describing their distinct portion.
• Assistant claims are frequently missed entirely because the surgical coder works from the primary surgeon's charge sheet. Reconcile assistant claims against the operating room schedule.
• Nonphysician practitioner assistants are paid at a further reduced percentage and must be enrolled and credentialed with the payer.

DME, Orthotics, and Braces

Dispensing braces and supports from the office is common in orthopedics and is billed under a separate system from professional services.

Requirements to Bill DMEPOS

• Supplier enrollment, and for Medicare a DMEPOS supplier number
• Compliance with applicable supplier standards and accreditation
• A valid, dated, signed order with the required elements
• Documented medical necessity in the clinical record
• Correct L code selection for the specific item furnished
• Proof of delivery retained in the record
• The KX modifier when the applicable coverage criteria are met and the policy requires it
• GA when a signed advance beneficiary notice is on file, or GY and GZ as applicable

Where DME Claims Fail

• Off-the-shelf versus custom-fitted confusion. Custom-fitted codes require substantial modification by a qualified individual, and billing a custom code for an item taken off the shelf and applied is a compliance exposure.
• Missing proof of delivery. The item was handed to the patient in the exam room and nothing was signed.
• Missing laterality modifiers on braces, which is a straightforward rejection.
• Competitive bidding and preferred supplier requirements that exclude the practice from billing certain items for certain patients.
• Same or similar equipment already on file for the patient within the reasonable useful lifetime.
• Items furnished during a global period that the payer considers included.

DME is worth doing well or not at all. A brace closet without a delivery-documentation workflow generates recoupment risk that exceeds the margin.

Prior Authorization Control

Prior authorization is the most common cause of large-dollar orthopedic write-offs, because the denied service is often the surgery.

Services That Commonly Require Authorization

• MRI, CT, and other advanced imaging
• Most inpatient and outpatient surgical procedures
• Viscosupplementation and other injectable drugs
• Spinal injections and pain procedures
• Bone growth stimulators and other higher-cost DME
• Physical and occupational therapy beyond an initial allowance
• Certain implants and biologics

Building an Authorization Workflow That Holds

1. Capture the authorization requirement at eligibility verification, by service type, not just as a yes or no for the plan.
2. Create the authorization request the day the service is ordered, with the conservative care documentation attached.
3. Record the approved codes, units, facility, provider, diagnosis, and date range as structured data, not as a note.
4. Reconcile the approved codes against the planned procedure before the date of service, and again against the operative note after.
5. Escalate to peer-to-peer review early. Waiting until the day before surgery removes every option.
6. Track expirations. Surgical authorizations expire, and rescheduled cases are a leading cause of denials.

The most expensive failure mode is a surgery that is performed with an authorization that covered a different CPT code than the one actually performed. When the operative plan changes intraoperatively, the billing team needs a defined path for retroactive authorization or appeal.

Place of Service and Site Selection

Place of service drives the facility versus nonfacility payment rate. Billing POS 11 for a procedure performed at an ASC overstates the professional payment and creates a refund obligation. Billing POS 24 for an office procedure understates it. This is a mechanical check that belongs in the scrubber.

Site-of-service authorization is separate from procedure authorization. Payers increasingly steer orthopedic cases to ASCs and may deny a hospital outpatient case that meets clinical criteria but was not approved for that setting. Confirm the approved facility, not only the approved procedure.

For practices with an ownership interest in an ASC, the professional and facility claims are separate submissions under separate rules. Reconciling them against each other catches cases where one side billed and the other did not.

Workers' Comp and Personal Injury

In many orthopedic practices, work injuries and accident cases are a double-digit percentage of volume and a disproportionate share of aged AR. They are not a variation on commercial billing. They are a different system.

Workers' Compensation

• Payment follows state fee schedules and state rules, not the practice's commercial contracts.
• Claims generally require the employer, date of injury, claim number, adjuster, and often the treating provider designation.
• Many states require jurisdiction-specific forms, progress reports, work status reports, or treatment authorization requests.
• Authorization rules are separate and often stricter, with utilization review and independent medical review processes.
• Appeal and dispute timelines are set by state law and can be short and unforgiving.
• Some services, such as impairment ratings, depositions, and narrative reports, are billed under state-specific codes and rates.

Auto, Personal Injury, and Liens

• Medical payments coverage, personal injury protection, and third party liability all behave differently, and the applicable one depends on the state and the policy.
• Letter of protection and lien cases can age for years. They need a separate aging bucket and a defined review cadence, or they will distort the practice's AR metrics and hide real problems.
• Attorney contact, settlement status, and balance verification need an owner. This is relationship follow-up, not claim follow-up.

The operational rule is simple: never let these cases sit in the same worklist as commercial claims. They need separate queues, separate follow-up intervals, and staff who know the jurisdiction.

ICD-10-CM Specificity

Orthopedic diagnosis coding fails in predictable ways, and nearly all of them are avoidable.

Laterality

Most musculoskeletal codes carry left, right, and unspecified options. Unspecified codes are increasingly denied outright, and a laterality conflict between the diagnosis and the procedure modifier is a hard stop for many payers.

Seventh Characters on Injury Codes

The initial encounter character reflects active treatment, not the first visit. The available characters differ between fracture categories and other injury categories, so the tabular list governs. The most common error is a template that carries the A character forward to every follow-up.

External Cause and Related Codes

External cause codes are not required by every payer but are frequently expected on injury claims, and workers' compensation carriers often want them. Where they are used, they should reflect the mechanism, place, activity, and status documented in the note.

Diagnosis Supporting Medical Necessity

For injections, advanced imaging, DME, and surgery, the diagnosis is what the payer tests against its coverage policy. A generalized pain code will not support a procedure that requires a specific structural diagnosis. Pull the covered diagnosis list from the applicable policy before the service, not after the denial.

Clean Claim Checklist

Before an orthopedic claim is released, confirm each of the following.

Patient and Case

• Correct payer, plan, and member identifier
• Case type identified: commercial, Medicare, work injury, or accident
• Claim number, adjuster, and date of injury present for work injuries
• Coordination of benefits resolved

Authorization

• Authorization on file and not expired
• Approved CPT codes match the codes billed
• Approved facility matches the place of service
• Approved rendering provider matches the claim
• Units billed do not exceed units approved

Coding

• Codes match the operative note or encounter note, not the schedule
• Global period checked on every code billed
• Correct global modifier applied where the encounter falls in a global period
• Modifier 25 or 57 supported by distinct documentation
• NCCI procedure-to-procedure edits reviewed with the correct indicator
• MUE limits reviewed for unit counts
• Add-on codes reported with a valid primary procedure

Anatomy

• Laterality modifier present and consistent with the diagnosis
• Digit modifiers present on hand and foot procedures
• Bilateral reporting in the payer's preferred format

Diagnosis

• Diagnosis specific to the documented condition and side
• Correct 7th character for injury codes
• Diagnosis supports the payer's medical necessity criteria
• Diagnosis pointers correct on each line

Drugs, Supplies, and Devices

• J code, units, and NDC correct where applicable
• Wastage documented and modifiers applied per payer policy
• Cast and splint supply codes match the material applied
• DME order, delivery documentation, and required modifiers on file

Claim Mechanics

• Place of service correct for where the service was performed
• Rendering, billing, and facility NPIs correct
• Referring provider present where required
• Operative note attached where the payer requires it

Common Denials and Corrections

Denials should be categorized by root cause and reviewed on a regular cadence. In orthopedics, a small number of root causes usually explain a large share of the dollars, and most of them are front-end problems that back-end appeals cannot permanently fix.

Recommended Billing Workflow

Daily

• Verify eligibility and benefits for tomorrow's schedule
• Work the authorization queue for newly ordered services
• Reconcile yesterday's encounters against charges entered
• Reconcile the operating room schedule against surgical charges
• Release clean claims and work scrubber edits
• Post payments and route denials to the correct queue

Weekly

• Review the unbilled surgical charge report with the operative note status
• Work authorizations expiring in the next 30 days
• Review encounters that fell inside open global periods
• Work denials by category, oldest and largest dollars first
• Review workers' compensation and personal injury queues separately
• Review credit balances and potential refunds

Monthly

• Review AR aging by payer, by case type, and by service line
• Review denial root causes and assign front-end owners
• Audit a sample of modifier 25, 59, and X modifier usage
• Audit a sample of DME delivery documentation
• Compare payments to expected contract rates by procedure family
• Review 99024 reporting against surgical volume

Orthopedic Billing KPIs

How RCM Staff Can Help

RCM Staff provides trained, healthcare-specific offshore staff who work inside your existing EHR, practice management system, clearinghouse, and payer portals. We do not replace your workflow with ours. We staff the operational work that orthopedic billing generates in volume:

• Eligibility and benefits verification, including facility and DME benefits
• Prior authorization submission, tracking, and expiration monitoring
• Charge entry and surgical charge reconciliation
• Coding support from industry-certified coders
• Global period tracking and postoperative visit review
• Claim scrubbing and submission support
• Payment posting and contract variance identification
• Denial tracking and appeal preparation
• Accounts receivable follow-up by payer and case type
• Workers' compensation and lien queue follow-up
• DME documentation and delivery-record management
• Payer portal work and billing inbox management
• Workflow and SOP documentation

Clinical decisions, final coding responsibility, and compliance oversight remain with the provider or organization. A medical virtual assistant can own the authorization log and the global period calendar so no surgery is scheduled without a valid approval and no postoperative visit is billed or written off by accident. Our medical coders support operative note coding and modifier review, and our medical billers handle the submission and follow-up volume. Learn more about our offshore medical billing model, or medical billing support from the Philippines.

If you want to size the opportunity first, the savings calculator and the in-house billing readiness grader are a useful starting point.

Frequently Asked Questions

Sources and References

1. CMS Medicare Learning Network, Global Surgery Booklet (MLN907166)
2. CMS Medicare Physician Fee Schedule
3. CMS Physician Fee Schedule Relative Value Files (global, bilateral, and multiple procedure indicators)
4. CMS Calendar Year 2026 Medicare Physician Fee Schedule Final Rule Fact Sheet
5. CMS National Correct Coding Initiative
6. CMS Medically Unlikely Edits
7. CMS Medicare Claims Processing Manual, Chapter 12, Physicians and Nonphysician Practitioners
8. CMS Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services
9. CMS Ambulatory Surgical Center Payment System
10. CMS Calendar Year 2026 OPPS and ASC Payment System Final Rule Fact Sheet
11. CMS DMEPOS Fee Schedule
12. CMS Place of Service Code Set
13. CMS Medicare Coverage Database
14. CMS HCPCS Quarterly Update
15. CDC ICD-10-CM Files

Related reading: physical therapy billing guide for practices with in-house therapy, wound care billing guide for postoperative and chronic wound work, and the revenue cycle management guide for the end-to-end process this guide sits inside.

Disclaimer: This guide is provided for general educational and operational reference only. It is not legal, compliance, clinical, reimbursement, or coding advice. Orthopedic billing requirements vary by payer, Medicare Administrative Contractor, state, provider contract, workers' compensation jurisdiction, facility, device, and date of service. CPT content is copyrighted by the American Medical Association. Code descriptions in this guide are simplified operational summaries and are not substitutes for the current official codebooks. CPT and HCPCS codes, code descriptors, global period assignments, coverage policies, authorization rules, modifiers, place-of-service requirements, NCCI edits, MUE values, and DMEPOS requirements change. Always confirm the current AMA CPT manual, HCPCS files, CMS guidance, the physician fee schedule relative value file, applicable Medicare contractor policies, payer medical policies, authorization terms, provider contracts, and state requirements before submitting claims. RCM Staff is an independent service provider and is not affiliated with, endorsed by, or certified by CMS, Medicare, Medicaid, the AMA, any Medicare Administrative Contractor, payer, workers' compensation board, implant or device manufacturer, DME supplier, EHR, or software vendor mentioned or implied in this guide.