What makes orthopedic billing services different
Orthopedic billing services have to follow a patient across the office, the imaging suite, the operating room and months of follow-up. A single episode can include a new-patient visit, an MRI authorization, a joint injection, an arthroscopy, post-operative visits inside a global period and a brace. Each piece follows different payment rules, and an error on any of them can hold up the rest.
Sports medicine adds another layer. The same knee injury may be billed to a health plan, workers' compensation, an auto policy or a school or league accident plan, depending on how it happened. Orthopedic medical billing works best when these questions are answered at scheduling, not after the first denial. The sections below explain the checks we run for orthopedic surgeons, sports medicine physicians and the groups that combine both.
Benefits, authorization and conservative care records
Office visits, ambulatory surgery and durable medical equipment can each carry different deductibles, coinsurance and network rules. We verify eligibility and benefits for each planned service and site, estimate the patient's share before surgery, and check whether a plan directs joint replacement or spine cases to specific facilities.
Many payers ask for proof of conservative treatment, such as physical therapy, medication or injections over a set period, before they approve advanced imaging, joint replacement or spine surgery. Authorizations are tied to specific codes, sides and facilities. When a surgeon adds a procedure or level in the operating room, the authorization needs a prompt update, because many payers allow only a short window after the date of service. Our prior authorization team requests approval by code and side and records the approval window.
Surgical global periods and global surgical package billing
Under Medicare's global surgery rules, a major procedure has a 90-day global period that covers the day before surgery, the day of surgery and the 90 days after. Minor procedures have a 0-day or 10-day period. The package includes the pre-operative visit after the decision for surgery, the procedure, routine post-operative visits and treatment of complications that do not need a return to the operating room. Global surgical package billing means knowing what is already paid for and what can still be billed.
| Modifier | When it applies | Effect on the global period |
|---|---|---|
| 24 | Unrelated E/M visit by the same physician during a post-operative period | Visit paid separately; global continues |
| 25 | Significant, separately identifiable E/M on the same day as a minor procedure or other service | Visit paid separately from the procedure |
| 57 | E/M on the day before or day of a major surgery that resulted in the decision to operate | Visit paid separately from the package |
| 58 | Staged or related procedure planned at the time of the first surgery, or more extensive than the original | A new global period begins |
| 78 | Unplanned return to the operating room for a related problem during the post-operative period | No new global period |
| 79 | Unrelated procedure by the same physician during the post-operative period | A new global period begins |
| 54 / 55 | Surgical care only / post-operative management only, when care is split between providers | Payment divided between providers |
Post-operative visits that fall inside the package are still worth recording. Medicare asks some practices to report them with 99024 so CMS can study global surgery data, and the code also helps a practice see how many no-charge visits each procedure generates. Commercial payers follow similar logic but may set different global days, so we check each payer's published policy.
Office and injection billing
Clinic days create most of the line items in orthopedic coding. A new complaint evaluated on the same day as a joint injection can support an E/M visit with modifier 25 when the note shows work beyond the usual pre-procedure assessment. A planned injection visit usually does not.
| Code | Service (summary) | Billing note |
|---|---|---|
| 20610 | Arthrocentesis, aspiration and/or injection of a major joint or bursa, without ultrasound guidance | 0-day global; drug billed separately with its HCPCS code and units |
| 20611 | Same service with ultrasound guidance, with permanent recording and reporting | Do not add a separate ultrasound guidance code |
| 29881 | Knee arthroscopy with meniscectomy, medial or lateral, including debridement or shaving | 90-day global; side reported with RT or LT |
| 29827 | Shoulder arthroscopy with rotator cuff repair | 90-day global |
| 27447 | Total knee arthroplasty | 90-day global; authorization usually required |
| 27130 | Total hip arthroplasty | 90-day global; authorization usually required |
Injected drugs, including corticosteroids and hyaluronan products, are billed with their own HCPCS codes and units based on the dose in the code descriptor. Fracture care codes include the first cast or splint, while replacement casts are billed separately where the payer allows. Fracture and injury diagnoses use a seventh character for the encounter, such as A for initial, D for subsequent and S for sequela, and the character must match the stage of care.
Bracing and DME claims
Braces and supports are billed with HCPCS L-codes. Medicare's DME contractors separate off-the-shelf orthoses, which need only minimal self-adjustment by the patient, from custom-fitted prefabricated orthoses, which need substantial modification by someone with expertise. The note has to describe the fitting and adjustment that supports the code chosen.
To bill Medicare for a brace dispensed in the office, the practice must be enrolled as a DMEPOS supplier, and the order and medical record must support medical necessity. Commercial plans may send bracing to a contracted DME vendor instead, so we check before the item is dispensed.
Sports medicine billing and the liable payer
Sports medicine billing starts with one question: who is responsible for the injury? It may be the patient's health plan, workers' compensation for injuries at work, auto or PIP coverage after a crash, or a school or league accident policy that often pays after the health plan. We ask how the injury happened at scheduling and collect claim numbers, adjuster contacts and policy details before the visit.
External cause codes, including activity codes in category Y93, tell the payer how and where the injury happened. Health plans often pend injury claims until the patient returns an accident questionnaire, so we follow up with the patient and the plan. Concussion follow-up visits rely on documented symptoms, testing and return-to-play decisions. When care moves into rehab, our physical therapy billing page covers plan-of-care and visit-limit rules.
Workers' comp claims in Texas
Texas workers' compensation follows rules set by the Texas Department of Insurance, Division of Workers' Compensation (DWC). Under Texas Labor Code 408.027 and DWC billing rules, a health care provider generally must submit a medical bill to the insurance carrier within 95 days of the date of service, and late bills can lose the right to payment unless an exception applies.
- Confirm the claim number, carrier, adjuster and date of injury before the first visit
- Check whether the service is on the DWC preauthorization list before treatment
- Complete the DWC-73 work status report when required
- Bill under the DWC medical fee guidelines, which DWC publishes and updates, not the commercial fee schedule
- Track carrier responses and request reconsideration or dispute resolution within the deadlines in DWC rules
Other states set their own fee schedules and deadlines, so out-of-state injury claims are checked against that state's rules.
Denials, AR and credentialing for orthopedic surgery billing
Common orthopedic surgery billing denials include a visit bundled into a global period, a missing modifier 25, 57 or 79, a side that does not match the authorization, an encounter character that does not fit the stage of care, and an injury claim pended for other coverage. We sort denials by reason and payer, correct and resubmit where the coding was wrong, and appeal with the operative note and authorization attached.
High-value surgical claims make payment variances costly, so we compare payments with contracted rates and pursue short pays. Surgeons who operate at an ASC or hospital also need every location on their payer files. Our credentialing and enrollment team tracks each application through a nine-stage process, from document collection and NPI and CAQH setup through payer applications, follow-ups and final approval.
How Fastora works with your practice
Fastora works in three phases. Our Virtual Assistant team handles scheduling, registration, insurance verification and copays collected upfront. Scriber support records visit documentation in your EHR in real time. Certified medical billing and coding professionals then handle claim submission, payment posting, denial management, AR follow-up and patient billing.
We work inside your existing EHR/PM system under the access you grant, with no software to install and no hidden setup fees, and we sign a BAA before accessing PHI. You get a dedicated account contact, transparent dashboards and a monthly review call. Review our complete medical billing services, see how pricing works, or request a free billing assessment.
Orthopedic practices that treat foot and ankle conditions in-house should also check podiatry billing for related procedure and DME-adjacent rules.
Orthopedic billing and coding services
As an orthopedic billing company, we run orthopedic billing and coding for surgical and non-surgical practices: fracture care global periods, surgical package coding, implant and hardware claims, and the authorization work that precedes every elective procedure. Post-surgical PT referrals stay coordinated with the therapy side so the episode bills cleanly from surgery through rehab. Related: physical therapy billing, medical coding services, free medical billing audit.