Orthopedics Billing: The Ultimate Guide to Getting Paid Right
Orthopedic billing is a unique subset of medical billing that demands precision, strong documentation, and familiarity with surgical and non-surgical services. Whether you’re running a private practice, ASC, or hospital-affiliated orthopedic department, understanding how to code and bill effectively for orthopedic services is essential for maintaining a healthy revenue cycle.
Table of Contents
Understanding Orthopedics Billing
Core Coding Systems Used
Commonly Billed Orthopedic Services
Global Surgical Package and Modifiers
Fracture Care Billing Nuances
Injections, DME, and Therapy Billing
Denials & Audit Risks
Payer-Specific Considerations
Compliance and Documentation Tips
Orthopedics Revenue Cycle Optimization
Understanding Orthopedics Billing
Orthopedics covers a broad range of services including:
Diagnostic imaging (X-rays, MRIs)
Conservative treatments (casting, bracing)
In-office procedures (injections, aspirations)
Surgeries (arthroscopies, joint replacements, fracture repairs)
Each service must be accurately coded to reflect the complexity and necessity of care, while meeting payer requirements and audit standards.
Core Coding Systems Used
CPT (Current Procedural Terminology)
Used for reporting procedures such as:
29881 – Knee arthroscopy with meniscectomy
27130 – Total hip replacement
20610 – Joint aspiration or injection
ICD-10-CM (Diagnosis Codes)
Essential to justify medical necessity:
M17.11 – Unilateral primary osteoarthritis, right knee
S82.202A – Displaced fracture of shaft of left tibia, initial encounter
HCPCS (For Supplies/Injectables)
Used for billing:
L1832 – Hinged knee brace
J1030 – Methylprednisolone acetate, 40mg (for joint injections)
Commonly Billed Orthopedic Services
Service CPT Code(s) Notes
Knee arthroscopy 29880, 29881 Use modifier 59 for distinct procedures
Joint injections 20610 Use J-code for medication
Casting and splinting 29065, 29125 Include application code + supply codes
Fracture care 27752 Bill as a global package, not an E/M
Trigger finger release 26055 Use modifier 51 if multiple surgeries
Physical therapy in-office 97110, 97140 Document time and medical necessity
Global Surgical Package and Modifiers
Orthopedic surgeries typically come with 90-day global periods, which include:
Pre-operative visit (1 day before)
Intra-operative procedure
Post-operative care (up to 90 days)
Key Modifiers:
24 – Unrelated E/M during global period
25 – Significant, separately identifiable E/M on same day as procedure
57 – Decision for surgery
78 – Return to OR for related procedure during global
79 – Unrelated procedure during global
59 – Distinct procedural service (e.g., separate anatomical site)
Example:
If a patient undergoes rotator cuff repair and then returns with a new knee issue within 90 days:
Use Modifier 24 on the E/M for the knee issue to indicate it's unrelated.
Fracture Care Billing Nuances
Orthopedic billing for fractures often leads to confusion. A common mistake is billing E/M + casting + X-ray instead of the global fracture care code, which includes all.
Example:
Closed treatment of distal radius fracture with manipulation
Correct CPT: 25605
Don’t bill E/M separately unless the patient is new or it’s unrelated.
Global Package Includes:
Application of cast/splint
Initial assessment
Follow-up visits related to fracture healing
Injections, DME, and Therapy Billing
Injections:
20610 – Major joint injection (knee, hip, shoulder)
J3301 – Triamcinolone acetonide 10 mg
Document consent, dosage, route, site, and medication lot number.
DME (Durable Medical Equipment):
Requires detailed written order (DWO), proof of delivery, and medical necessity.
Physical Therapy:
97110 – Therapeutic exercises
97112 – Neuromuscular re-education
Document time spent and therapist credentials.
Denials & Audit Risks
Top reasons orthopedic claims are denied:
Denial Reason Avoidance Strategy
Missing/modifier errors Educate staff on correct modifier usage
No prior authorization Verify requirements during scheduling
Poor documentation Use checklists for surgery and fracture notes
Billing within global period Use modifiers 24, 78, 79 appropriately
Bundling issues Use Modifier 59 where allowed
Payer-Specific Considerations
Medicare:
Requires ABNs for non-covered services.
Limits on number of injections per site annually.
Workers’ Comp:
Pre-auth almost always required.
Follow jurisdiction-specific billing rules.
Private Insurers:
Have varying bundling rules and DME policies.
Require consistent documentation and prior auth.
Compliance and Documentation Tips
Use orthopedic-specific templates in EHRs.
Document ROM, imaging results, and failed conservative care.
Include full operative details and rationale.
Maintain updated provider credentialing and NPI info.
Orthopedics Revenue Cycle Optimization
Verify insurance eligibility in advance.
Automate prior authorization tracking.
Use scrubbing software to minimize claim rejections.
Educate front desk on collecting copays and deductibles.
Monitor AR aging and pursue follow-ups aggressively.
Final Thoughts
Orthopedic billing is intricate but manageable with the right expertise, systems, and processes. From understanding fracture care rules to mastering global modifiers and payer policies, your ability to get paid hinges on coding accuracy and compliance. Whether you're billing in-house or through a partner, investing in orthopedic billing knowledge is a must for financial health.
