Everything You Should Know About Orthopedic Medical Billing
Orthopedic doctors treat bones, joints, muscles, and ligaments. They fix broken bones, replace hips and knees, and help patients walk without pain. But after each visit or surgery, someone must turn every service into the right medical codes and bills. That job is called orthopedic medical billing. Done well, it brings steady cash to the practice. Done poorly, it causes denials, delays, and lost revenue.
At MZ Medical Billing, we manage orthopedic billing every day. In this guide we share—in clear, simple language—everything you should know: common codes, payer rules, documentation tips, and ways we help orthopedic clinics get paid fast and in full.
1. Why Orthopedic Billing Is Different
High‑value procedures. Joint replacements and spine surgeries can cost tens of thousands of dollars. Even a small coding error can mean a big loss.
Multiple payers. Orthopedists work with Medicare, Medicaid, workers’ comp, commercial plans, and sometimes auto insurance—all with different rules.
Global surgery periods. Many orthopedic surgeries have 90‑day “global” periods. During that time, routine follow‑up visits are included in the original fee and cannot be billed again.
Device and implant charges. Screws, plates, and artificial joints add extra lines to a claim. Each item must be listed with the correct HCPCS code and invoice cost.
Modifier heavy. Orthopedic encounters often need modifiers like –RT (right side), –LT (left side), –59 (separate service), or –24 (unrelated E/M during global period).
Because of these factors, orthopedic billing requires special skill and constant attention to payer updates.
2. Key Code Sets in Orthopedics
CPT® (Current Procedural Terminology)
These five‑digit codes describe what the surgeon did. Examples:
20610 – Arthrocentesis, major joint (shoulder, hip, knee).
27130 – Total hip replacement.
29827 – Shoulder arthroscopy with rotator‑cuff repair.
63047 – Lumbar laminectomy for spinal stenosis.
ICD‑10‑CM (Diagnosis Codes)
These explain why the patient needed care.
M17.11 – Unilateral primary osteoarthritis, right knee.
S82.201A – Unspecified fracture of shaft of right tibia, initial encounter.
M48.06 – Spinal stenosis, lumbar region.
Z96.641 – Presence of right artificial knee joint.
HCPCS Level II
These describe supplies and implants.
L8699 – Prosthetic implant, not otherwise specified.
C1776 – Joint device, total knee.
Q4101 – Apligraf (skin substitute used in foot‑and‑ankle surgery).
Coders must match procedure, diagnosis, and device codes so the claim passes automated edits.
3. Understanding the Global Surgery Package
Most open and arthroscopic orthopedic surgeries fall into a 90‑day global period. Medicare and many commercial payers include:
Pre‑operative visit the day before or day of surgery.
The surgery itself.
All routine post‑op visits for 90 days.
You cannot bill normal follow‑up visits separately. However, you can bill:
Unrelated care (modifier –24 on the E/M code).
Return to the OR for complications (modifier –78).
Add‑on procedures not planned at the first surgery.
Failing to use the right modifiers is a frequent denial cause.
4. Documentation Essentials
Insurers require proof every code is correct. Good orthopedic notes include:
Exact anatomical site (right/left, specific bone or joint).
Type of fracture (open vs. closed, displaced vs. nondisplaced).
Imaging results (X‑ray, MRI) that justify surgery.
Conservative care tried first (physical therapy, injections) when billing major joint replacements—some payers demand it.
Implant log with part numbers and cost.
Time spent on certain procedures if time drives code selection.
Clear documentation prevents audits and supports appeals.
5. Common Denial Reasons in Orthopedic Billing
Missing laterality. Forgetting –RT or –LT causes “incomplete code” denials.
Global period errors. Billing a routine follow‑up as new care.
Wrong modifiers on multiple procedures. Using –51 instead of –59 can cut payment.
Medical necessity. Payers want proof conservative treatment failed.
Implant invoice not attached. Some carriers need hard cost evidence.
Workers’ comp authorization gaps. Surgery done before pre‑auth is approved.
Bundled CPT codes. Billing components separately when a comprehensive code exists.
We track every denial reason in a dashboard, spot trends, and fix issues fast.
6. How We Improve Orthopedic Revenue Cycles
Advanced Claim Scrubbing
Our AI checks laterality, modifiers, device codes, and global rules before the claim leaves the door. Clean‑claim rates stay above 98 percent.
Dedicated Orthopedic Coders
Our certified coders focus only on bones, joints, and spine. They know NCCI edits and payer quirks so coding is right the first time.
Real‑Time Eligibility and Authorization
We verify benefits and secure prior authorizations quickly, preventing last‑minute cancellations or unpaid surgeries.
Implant Tracking
We store implant invoices, link them to HCPCS lines, and attach docs for payers that need cost proof.
Post‑Op Edit Alerts
During the 90‑day global period, our system flags any E/M code lacking a –24 or –57 modifier, preventing automatic denials.
Aggressive Denial Management
If a claim is denied, we appeal with operative notes, imaging, and payer policy excerpts. Our orthopedic appeal win rate tops 85 percent.
Clear Monthly Reports
You see days in A/R, denial reasons, and revenue by procedure—simple charts you can explain at staff meetings.
7. Workers’ Compensation and Auto Accident Billing
Orthopedic practices often handle job or car injuries. These payers need:
Clinical notes linking injury to work or accident.
Employer/insurer pre‑authorization.
Detailed bills following state fee schedules.
LOP (Letter of Protection) tracking in auto cases.
We keep separate payer groups, so commercial and injury claims never mix.
8. Telehealth and Remote Physical Therapy Visits
Since COVID‑19 many orthopedists offer telehealth check‑ins and remote PT guidance. Use:
99441–99443 for phone E/M.
99202‑99215 with –95 for video visits.
97110 or 97112 with –95 when PT supervises exercises live on video (if payer allows).
We update telehealth rules weekly and deny‑proof claims before submission.
9. Key Performance Indicators (KPIs) for Orthopedic Billing
Clean‑Claim Rate > 98 %. Percent of claims accepted on first pass.
Days in A/R < 25. Lower means faster payment.
Denial Rate < 5 %. Portion of claims denied by payers.
Net Collection Rate > 95 %. Money collected vs. allowed amount.
Charge Lag < 2 days. Time from visit to claim submission.
Appeal Success Rate > 80 %. How often our appeals overturn denials.
We track these KPIs for every client, share dashboards, and meet monthly to plan improvements.
10. Steps to Start with MZ Medical Billing
Quick Call. We learn your pain points—global errors, implant mapping, aging A/R.
Data Review. You send sample EOBs and op notes. We show missed revenue.
Custom Plan. We map workflows to your EHR, ASC, or hospital system.
Secure Integration. We connect through HIPAA‑compliant portals—no downtime.
Go Live. Claims flow in days; you watch denials drop.
Ongoing Support. One account manager, weekly AR reports, monthly strategy calls.
Our fee starts at just 2.99 percent of collections, with zero hidden charges, covering 70‑plus specialties—including every orthopedic subspecialty—across all 50 states.
11. Frequently Asked Questions
Q: Do I need new software?
A: No. We integrate with popular systems like Athena, eClinicalWorks, Epic, and ASCs’ proprietary platforms.
Q: How long is the contract?
A: Month‑to‑month. Stay only if you see value.
Q: Who answers patient billing questions?
A: Our U.S.‑based team handles calls, sets payment plans, and keeps your front desk free.
Q: Can you help with old A/R?
A: Yes. We run focused cleanup projects on claims 90 + days old and often recover thousands.
Conclusion
Orthopedic medical billing is complex—global periods, implant charges, tricky modifiers, and multiple payers. Small mistakes can cost big money. By partnering with MZ Medical Billing, you get a team that lives and breathes orthopedics. We combine advanced claim scrubbing, expert coders, and clear reports to cut denials and speed payments. Your staff can focus on healing bones and joints while we keep your revenue cycle healthy.
Ready to see how much faster your orthopedic claims can be paid? Contact us today for a free analysis of your current billing and a plan to boost your income—without hidden fees or long contracts.