Orthopedic billing
Global periods, modifiers and drug units checked before every orthopedic claim goes out.
We bill orthopedics the way Medicare’s global surgery rules read it: the right modifier inside 0, 10 and 90-day globals, fracture care and casting coded to NCCI, injections billed per joint with drug units, and injury claims sent to the right payer first.
- Full-service rate
- 3% to 6% of collections
- Medicare global periods
- 0, 10 and 90 days
- Global surgery modifiers
- 24, 25, 57, 58, 78, 79
- New & smaller practices
- Flexible monthly minimum
What makes orthopedic billing different
Most orthopedic revenue sits inside a global surgery package. Medicare pays one fee for the procedure and the routine care around it: nothing after a 0-day code, 11 days for a 10-day code and 92 days for a major surgery, according to the CMS global surgery booklet. Groups of 10 or more in nine states, Florida and Ohio among them, must also report post-op visits for listed procedures with 99024.
A visit, injection or return to the OR in that window pays only with the right modifier. We bill it, with fracture care, x-rays, braces and injury claims, inside our full revenue cycle service at 3% to 6% of collections.
The modifiers that bill inside a global period
Medicare’s rules, from the CMS booklet (December 2025). Commercial plans use the same modifiers with their own edits.
- 24An unrelated E/M by the same surgeon during the post-op period. The note must show why it is unrelated.
- 25A significant, separately identifiable E/M on the day of a minor procedure, such as a joint injection. No second diagnosis needed.
- 57The visit that led to the decision for major surgery, on the day before or the day of a 90-day procedure.
- 58A staged or related procedure: planned at the first surgery, more extensive, or therapy after a diagnostic procedure. A new global starts.
- 78An unplanned return to the OR for a related problem in the post-op period, billed with the code for what was done.
- 79An unrelated procedure by the same surgeon in the post-op period, such as the other knee. A new global starts.
- 54 and G055954 goes on the surgery when another practitioner is expected to give part of the post-op care. G0559 is the add-on for post-op visits outside the surgical group.
- 50, RT and LTMedicare wants a bilateral procedure on one line with 50 unless the code already says bilateral. ASCs bill two lines with RT and LT.
Fracture care, casting and supplies
Most fracture treatment codes carry a 90-day global, and all include the first cast, splint or strapping, so when you treat the fracture and keep the patient, no casting code goes on top, under chapter IV of the 2026 NCCI policy manual. Removing a cast your own group applied is included too.
When you only stabilize the injury and someone else gives the definitive care, you bill the E/M (if separately identifiable), the casting or splinting code and the supply code (Q4001 to Q4051). Several similar bones in one cast without manipulation, such as three metatarsals, are one unit.
Joint injections and drug units
Joint injection codes (20600 to 20611) are billed per joint: a shoulder injected with two of its bursae is one unit. In the 2026 fee schedule file, a shoulder is 20610 without ultrasound or 20611 with it, both 0-day codes. Guidance is built into 20611, so no separate ultrasound code goes with it. An injection into a joint operated on that day is not billed.
The decision to inject is part of the injection. An E/M the same day needs separately identifiable work and modifier 25, and NCCI says a new patient alone is not enough.
The drug goes on its own line in units of its HCPCS dose. J3301 (triamcinolone acetonide) is per 10 mg in Medicare’s 2026 drug payment files, so 40 mg is 4 units. For drugs from single-dose vials, Medicare requires JW for the discarded amount or JZ when none was discarded, under its JW and JZ policy.
In-office x-rays and bracing
Diagnostic x-rays are outside the global package, so films at a post-op visit are billed. If you own the equipment and read the film, the x-ray bills globally; for a hospital patient you bill only the reading (modifier 26), under chapter 13 of the Medicare Claims Processing Manual. Film x-rays carry FX and computed radiography FY, each paid less.
Braces dispensed from the office are not billed on your physician claim. Under 42 CFR 424.57, Medicare pays for them only after the practice enrolls as a DMEPOS supplier (form CMS-855S) and gets a supplier number. Physicians supplying only their own patients are exempt from the $50,000 surety bond.
Prior authorization for MRI and surgery
Under Medicare’s WISeR model, from January 1, 2026 through 2031, knee arthroscopy for knee osteoarthritis is reviewed in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington: you request prior authorization, or the claim is reviewed before payment.
Medicare Advantage, Medicaid and commercial plans keep their own lists. Our prior authorization team checks the plan when an MRI, CT or surgery is ordered and tracks the approval to the date of service.
Workers’ compensation and auto claims
For a work or accident injury, the workers’ comp, no-fault or liability insurer pays before Medicare, and CMS’s Medicare Secondary Payer booklet says to bill it first. If it denies or does not pay within 120 days, Medicare may pay conditionally and recover later, and a claim without the primary payer’s denial reason is denied. We record the claim number, adjuster and employer at intake.
Why orthopedic claims deny
Common orthopedic denials, with the reason codes that often carry them (codes vary by payer):
- A visit or procedure inside a global period without 24, 25, 57 or 79 (CO-97)
- A modifier that does not fit the code, such as 57 on a minor procedure (CO-4)
- Casting billed with the fracture code, or an injection with surgery on that joint (CO-236)
- Two units of an injection code for one joint (CO-151)
- No authorization on file for an MRI or surgery (CO-197)
- An injury claim sent to the health plan instead of work comp, liability or no-fault (19, 20 or 21)
Each goes through our denial management process, and our CO-97 guide shows when a corrected modifier fixes a bundling denial and when it does not.
How we run orthopedic billing
Map payers and globals
Each payer’s modifier and authorization rules are set up, and every global period is tracked.
Flag injury claims
Work comp, auto and liability cases are identified at intake.
Code from the op note
Laterality, modifiers, NCCI edits, drug units and JW or JZ are checked before the claim goes out.
Work what comes back
Denials are sorted by payer and reason, then corrected or appealed with the op note.
Report monthly
Collections, days in A/R, denials by reason and open injury claims, by surgeon.
Credentialing for orthopedic practices
An orthopedic group needs more enrollments than it expects: every surgeon, PA and NP who bills, hospital and surgery center privileges, and a DMEPOS supplier enrollment if you dispense braces. Our provider credentialing service handles Medicare (PECOS), Medicaid and commercial applications at $189 per payer application, less in bulk.
Not sure your globals and modifiers are right? Send us a month of surgical claims with the op notes and we’ll check them, free.
Medicare uses three. A 0-day code has no post-op period, a 10-day code covers the surgery day and the next 10, and a 90-day major surgery covers 92 days: the day before, the day of and 90 days after. Most fracture treatment codes are 90-day and joint injections 0-day; each code’s period is in the fee schedule.
Use 57 on the visit that led to the decision for a major (90-day) surgery, on the day before or the day of it. Use 25 for a significant, separately identifiable E/M on the same day as a minor procedure (0 or 10-day). For a minor procedure, the decision to do it is part of the procedure.
Yes, when the visit includes separately identifiable work beyond deciding to inject, billed with modifier 25. A different diagnosis is not required, and a new patient is not enough on its own. The injection is billed per joint, and the drug on its own line in units of its HCPCS dose.
Not when you treat the fracture and keep the patient: the fracture code includes the first cast or splint and removing it. When you only give initial care and send the patient on, you can bill a separately identifiable E/M, the casting or splinting code and the supply code.
Our full-service rate is 3% to 6% of monthly collections, set by your volume, with no setup or onboarding fees and flexible monthly-minimum plans for new and smaller practices. It covers eligibility checks, prior authorizations, coding, claims, payment posting, denials and A/R follow-up. Your exact rate comes after a free A/R review. Our guide to medical billing costs shows how to compare quotes.
Yes. We don’t list our clients on this site, but ask us and we’ll arrange it: with a current client’s permission, we share their contact details so you can hear how we work from them directly.
From our guides
How to calculate days in A/R
The formula with a worked example and a calculator, the benchmarks, why a good average can hide old claims, and the fixes that bring days in A/R down.
How much do medical billing services cost?
The four ways billing companies price their work, the fees that sit outside the rate, and in-house arithmetic built from BLS data, so you can compare quotes on your own numbers.
Send us your last 90 days of orthopedic claims.
We’ll review them free and show you where global periods, modifiers or drug units are costing you money.