Specialties
Orthopedic Billing Services
Orthopedic revenue is driven by surgery, and surgery is governed by global periods: what is included before and after the operation, which follow-up visits are billable, and which modifiers unlock the rest. Add laterality, bilateral formats that differ by payer, bracing and a steady flow of work-injury cases, and small errors repeat across a whole surgical schedule.
- Global period tracking for every surgical patient
- Laterality, bilateral and finger or toe modifiers set to each payer's format
- Surgery and MRI authorizations obtained before the date is booked
What makes orthopedic billing different
Most orthopedic procedures carry a 90-day or 10-day global period. During that window, routine post-operative visits are part of the surgical payment, but an unrelated problem, a staged second procedure or an unplanned return to the operating room can be billed with the right modifier. Without a reliable view of which patients are inside a global, practices either give away billable work or send claims that deny as included.
Body-side detail matters on almost every claim. Knee, shoulder, hand and foot procedures need RT or LT, digits use their own modifiers, and bilateral procedures are reported one way for Medicare and sometimes differently by other payers. The same operation can deny at one payer and pay at another purely because of how the line was formatted.
Then there is the setting. Surgeons operate in hospitals and ASCs where the facility bills separately, while injections, casting and bracing happen in the office with their own supply and drug codes. A meaningful share of patients are injured at work or in vehicle accidents, so the right payer is often not the patient's health plan at all.
Orthopedic codes, globals and modifiers
The parts of the code set that cause most orthopedic rework. Use the current CPT and HCPCS code sets and each payer's policy as the final word.
| Area | What it covers | Billing notes |
|---|---|---|
| Global surgical package | Pre-operative visit the day before or day of surgery, the procedure, and routine post-operative care for 90 days (major) or 10 days (minor). | Post-operative visits inside the global carry no separate charge; CMS requires some practices to report them with 99024. |
| Modifiers 24, 58, 78, 79 | Unrelated visit, staged or planned related procedure, unplanned return to the OR, and unrelated procedure during the global period. | 58 and 79 start a new global period, and 78 marks an unplanned trip back to the OR for a problem linked to the first surgery. The modifier must match what the operative note says. |
| RT, LT, 50, F1 to FA, T1 to TA | Side of the body, bilateral procedure, and individual fingers and toes. | Medicare wants one line with modifier 50 and one unit. Other payers set their own format, which can be two lines with RT and LT, so keep a per-payer rule. |
| Modifier 51 and multiple procedures | Additional procedures in the same session. | Payers reduce secondary procedures, so the highest-valued procedure goes first; 59 or XS applies to a separate site only when those procedures are not normally performed together. |
| 20610, 20611 and drug J-codes | Major joint arthrocentesis or injection, without or with ultrasound guidance, plus the drug injected. | 20611 describes the injection with ultrasound guidance and 20610 the injection without it. The drug and its units are matched to the drug code's descriptor. |
| Fracture care and casting | Closed and open fracture treatment codes, cast and splint application (29000 to 29799), and casting supplies. | Fracture treatment codes include the cast, splint or strapping applied with them, so a casting code is not added to the same treatment. |
| Assistant at surgery: 80, 82, AS | Assistant surgeon, assistant when no qualified resident is available, and non-physician assistant. | Medicare pays an assistant only for procedures where its fee schedule allows one; other payers keep their own lists. |
CPT is a registered trademark of the American Medical Association.
Official sources: CMS Claims Processing Manual, chapter 12 (external site), CMS MLN: Global surgery booklet (external site), CMS NCCI Policy Manual, chapter 4 (musculoskeletal) (external site), CMS NCCI Policy Manual, chapter 1 (modifiers) (external site), CMS: Physician fee schedule relative value file (code descriptors) (external site), eCFR: 42 CFR 424.57 (DMEPOS supplier standards) (external site), eCFR: 42 CFR 416.164 (ASC packaged services) (external site)
Where orthopedic claims get denied
Visits billed inside the global period
A post-operative visit sent as a normal E/M without 24 or 25, or for a problem that the payer sees as related to the surgery.
Bilateral format mismatch
Modifier 50 sent to a payer that expects RT and LT lines, or the reverse, including units and charge amounts entered the wrong way.
Missing laterality or digit modifiers
Edits reject the claim, or a second procedure on the opposite side looks like a duplicate.
No authorization for the MRI or the surgery
Advanced imaging and elective joint and spine procedures are common authorization targets, and the approval must match the CPT code performed.
Bracing billed without supplier enrollment
Orthotics billed to Medicare need DMEPOS supplier enrollment and must meet the supplier standards, including proof of delivery.
Work and auto injuries billed to the health plan
The health plan denies as another party's liability, and the workers' comp or auto claim is opened late.
Our orthopedic billing process
Step 1: Track every global
Each surgery opens a global window on the patient account, so follow-up visits are flagged as included or billable with the right modifier.
Step 2: Keep a payer format sheet
Bilateral, multiple-procedure and assistant-at-surgery rules are recorded for each payer you bill.
Step 3: Authorize at booking
Imaging and surgical cases are checked for authorization when they are scheduled, with the approved CPT codes matched to the operative plan.
Step 4: Route injury cases first
Work and accident questions are asked at intake, so workers' comp, auto or liability payers are billed from the start.
Step 5: Reconcile office supplies
Injections, casting supplies and braces are matched to the visit so drugs, units and supplies are not left off the claim.
Orthopedics, workers' comp and pain management
Work injuries make up a large part of many orthopedic schedules, and they follow state workers' compensation rules, which set how treatment is approved and how it is paid. Our workers' comp billing service handles those claims on their own track so they do not mix with group health A/R.
Orthopedic groups that offer spine injections overlap with pain management. The injection codes are shared, but orthopedic billing is anchored in surgical globals, while pain practices bill repeat procedures governed by frequency limits and coverage policies. When both exist in one group, each provider's claims follow the rules of the service they actually performed.
Frequently asked questions
How should we bill a bilateral knee procedure?
It depends on the payer. Medicare expects a single line with modifier 50 and one unit, while other payers may want two lines with RT and LT. Keeping a payer-by-payer rule avoids most bilateral denials.
Can we bill an office visit during the post-operative period?
Routine follow-up is included in the surgical payment. A visit for an unrelated problem can be billed with modifier 24. Visits for problems the payer sees as related stay inside the global.
Who bills for the implant in a joint replacement?
In an ASC, implanted devices are generally part of the facility's payment unless they have pass-through status, and the surgeon bills the professional service. Hospital outpatient rules and commercial contracts can differ, so we check the setting and payer.
Do we need a supplier number to bill braces?
To bill Medicare for orthotics the practice generally needs DMEPOS supplier enrollment and must meet the supplier standards, including proof of delivery. Commercial plans have their own rules.
What changes when an injury happened at work?
The claim goes to the employer's workers' comp carrier instead of the health plan, using the claim number and date of injury, and treatment usually needs adjuster approval first.
Related services and specialties
Related services
Workers' Comp Billing
Work-injury claims billed to the right carrier with claim numbers, adjuster approvals, required reports and state fee schedules.
Learn more about Workers' Comp BillingDenial Management
Denials worked by reason code and root cause, with corrected claims and appeals filed inside payer deadlines.
Learn more about Denial Management
Specialties
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Timed therapy codes and the 8-minute rule, GP modifiers, KX thresholds, plan-of-care certification and visit limits.
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Epidurals, facet and medial branch blocks, radiofrequency ablation, imaging-guidance bundling and urine drug testing coded to coverage policy.
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Routine foot care exceptions, class findings and Q modifiers, nail and callus debridement, foot surgery globals and the diabetic shoe program.
Learn more about Podiatry Billing
Check your surgical claims for missed revenue
A free audit looks at global period visits, bilateral and modifier denials, and authorization problems on your orthopedic claims.