Orthopedics billing
Orthopedics is a global-period specialty. Most of the money that goes missing is not denied — it is bundled into a surgical package that was never supposed to cover it, or an implant and supply that nobody charged for.
What actually gets denied
Major procedures carry a 90-day global period, minor ones 10 or zero. Post-op visits inside the window are not separately payable unless unrelated, and unrelated has to be proven with modifier 24 plus a distinct diagnosis.
An injection performed at a visit does not automatically make the visit billable. The E/M must be significant, separately identifiable and documented as its own evaluation — this is one of the most audited modifiers in the specialty.
Bypassing an NCCI edit with 59 when the services were not distinct is the fastest route to a payer audit. The X{EPSU} subsets are more specific and better defended.
Braces, casting supplies and implants dispensed in the office are frequently documented clinically and never captured on a claim. Recovering that requires a charge-capture reconciliation, not a denial appeal.
Payer behavior
Second and subsequent procedures in the same session pay at a reduced percentage, and the payer's sequencing is not always the same as yours. Sequencing by RVU protects the allowable.
Whether a procedure supports an assistant, and at what modifier, is code-specific and payer-specific.
State fee schedules, required forms and adjuster-driven timelines are a separate operational track from commercial A/R.
Documentation traps
Approach, laterality and structures treated must be explicit; a code chosen from a scheduling sheet will not survive review.
RT, LT and modifier 50 with a matching laterality in the diagnosis are not optional.
Return-to-OR and complication rules require the reason to appear in the note.
Every orthopedics account is staffed by coders who bill this specialty daily. The work spans our full medical billing and revenue cycle management services — coding, claim scrubbing, denial management and A/R recovery — and you can see how engagements are structured on our pricing page. For the full specialty bench, go back to all specialties we bill, or contact us at (555) 555-0142.
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