Orthopedic Medical Billing: Complete Guide for Orthopedic Practices 2026

Orthopedic Medical Billing: Complete Guide for Orthopedic Practices

Orthopedic medical billing encompasses a wide range of musculoskeletal procedures from fracture care and joint replacements to arthroscopic surgeries and spine procedures. Understanding surgical package definitions, global period rules, modifier usage for staged procedures, and the complex coding requirements for trauma care is essential for orthopedic practices to maximize reimbursement while maintaining compliance with payer regulations.

Surgical Package and Global Period Rules

Orthopedic surgeries include 90-day or 10-day global periods covering pre-operative evaluation, the surgery itself, and post-operative care. Understanding what's included in the surgical package versus separately billable prevents denials. Post-operative visits for the same condition are bundled, but complications, new problems, or treatment of other conditions can be billed separately with modifier 24.

Staged procedures planned at the time of initial surgery require modifier 58, while unplanned return to the OR requires modifier 78 for related procedures or 79 for unrelated procedures. Each modifier affects reimbursement differently—58 starts a new global period with full payment, while 78 pays only the surgical component. Documentation must clearly indicate whether complications necessitated return to surgery or if staged procedures were planned from the beginning.

Fracture Care and Cast Application

Fracture treatment codes include initial treatment, subsequent cast changes, and follow-up care within the global period. Closed treatment without manipulation, closed treatment with manipulation, and open treatment each have distinct codes. Cast application codes are separately billable only when casting is the sole service provided—when casting follows fracture reduction, it's included in the fracture care code.

Emergency department orthopedic consultations for fractures require careful coding. If the orthopedist provides initial fracture care, the E/M service is included in the fracture care code. However, if only consultation without treatment is provided, E/M codes with appropriate modifiers should be billed. Understanding these distinctions prevents unbundling errors while ensuring appropriate payment for services rendered.

Joint Replacement and Arthroplasty Coding

Total joint replacements are high-value procedures requiring accurate coding of the primary procedure, approach, and any additional components. Revision arthroplasty codes differ from primary replacements and require documentation of what components are being revised. When both acetabular and femoral components are revised during hip revision surgery, both components must be coded separately.

Bundled payment models like CJR (Comprehensive Care for Joint Replacement) affect how orthopedic practices are reimbursed for joint replacements. Understanding episode-based payment, quality metrics, and reconciliation processes is critical for practices participating in these programs. Documentation must support medical necessity, appropriate patient selection, and lack of complications to optimize bundled payment reconciliation.

Arthroscopy and Minimally Invasive Procedures

Arthroscopic procedures follow add-on coding rules where the primary most complex procedure is listed first, followed by additional procedures. Understanding which arthroscopic codes can be billed together requires knowledge of NCCI edits and CCI column logic. Surgical arthroscopy codes include diagnostic arthroscopy, so separate billing for diagnostic scope with surgical scope constitutes unbundling.

Documentation must specify each compartment explored, all procedures performed, and findings in each area. Operative reports should clearly differentiate between diagnostic visualization and therapeutic intervention. When multiple procedures are performed arthroscopically, use modifier 51 for multiple procedures (though many payers apply this automatically). Payment follows standard multiple procedure rules with the highest-paying procedure at 100% and additional procedures at reduced percentages.

Modifiers Critical to Orthopedic Billing

Modifier 50 for bilateral procedures, modifier 59/XS/XU for distinct procedural services, modifier 76 for repeat procedures, and modifiers LT/RT for laterality are frequently used in orthopedic billing. Modifier 22 for increased procedural services allows additional payment when surgery is significantly more complex than typical, but requires detailed documentation and often results in manual review.

Modifier 25 allows E/M billing on the same day as minor procedures when significant separately identifiable evaluation is performed. This is commonly used when patients present for post-operative follow-up but also have new problems requiring evaluation. Documentation must clearly show the E/M service was above and beyond the usual pre- and post-procedure care.

Workers Compensation and Personal Injury

Orthopedic practices frequently treat work-related injuries and motor vehicle accident patients. Workers compensation billing follows different rules than traditional insurance, often requiring specific forms, narrative reports, and medical-legal documentation. Many states have fee schedules that differ from Medicare rates, and authorization requirements are typically more stringent.

Personal injury cases may involve liens, letters of protection, or litigation holds. Understanding state regulations regarding balance billing, obtaining proper authorizations, and maintaining detailed records is essential. Many practices require upfront payment arrangements or attorney guarantees before treating personal injury cases due to reimbursement uncertainty.

Successful orthopedic billing requires expertise in surgical package rules, fracture care coding, joint replacement procedures, arthroscopic billing, and critical modifier application. Orthopedic practices that partner with specialized billing services achieve improved collections, reduced denials, and optimal reimbursement.