Orthopedics Medical Billing & Revenue Cycle ManagementOrthopedics Medical Billing & Revenue Cycle Management

What makes orthopedic billing difficult?

Major orthopedic surgery carries a long global period, so the practice has to know which follow-up visits are included and which can be billed. Surgeries often involve several procedures or both sides of the body, plus implants and braces. Many patients are also covered by workers' compensation or auto insurance, which follow different rules from health plans.

What are the most common orthopedic billing pitfalls?

• 90-day global periods. Major surgery includes routine postoperative visits for 90 days. Visits for unrelated problems, staged procedures or returns to the operating room in that window need the right modifier, or they are denied as part of the global payment.
• Multiple-procedure and bilateral modifiers. When several procedures are done in one session, payers reduce payment for the additional ones, and bilateral procedures follow payer-specific rules for modifier 50 or right and left modifiers. The wrong choice leads to denials or underpayment.
• Implant and DME billing. Implants, braces, splints and other durable medical equipment are billed with their own supply codes and documentation. Some payers require separate authorization or supplier enrollment for DME.
• Workers' comp and auto-injury claims. These claims need the employer or carrier details, claim number and injury date, and follow state rules and fee schedules rather than the patient's health plan. Sending them to the health plan delays payment.
• Prior authorization. Advanced imaging, joint replacement, spine surgery and some injections often need approval. The approval must match the procedure, side and site of service actually performed.

What causes orthopedic claim denials?

Denials usually come from postoperative visits billed inside a global period, missing or wrong surgical modifiers, missing authorization, and injury claims sent to the wrong payer. Implant and DME claims are also denied when documentation or supplier requirements aren't met.

How do you handle eligibility and prior authorization for orthopedics?

We verify coverage before the visit and identify whether the injury belongs to workers' compensation, auto insurance or the health plan. Where approval is needed for imaging, surgery or injections, we request it before scheduling and match it to the procedure and side that will be billed.

How are orthopedic claims coded and submitted?

Each claim is checked for the right procedure codes, surgical and laterality modifiers, global period status and diagnosis order. Injury claims go out with the carrier, claim number and injury date the payer requires, and supply claims with the documentation for each item.

How do you handle payment posting and AR follow-up for orthopedics?

Payments are posted by line, so multiple-procedure reductions and implant payments can be checked against what each payer should pay. Unpaid claims are worked by payer and filing deadline, and workers' compensation and auto claims are followed up with the carrier and adjuster.

Do you handle credentialing and enrollment for orthopedic surgeons?

Yes. We help enroll orthopedic surgeons and other providers with Medicare and commercial plans and keep enrollment current. Practices that dispense braces or other DME may need separate supplier enrollment, which we check during setup.

How does onboarding work for an orthopedic practice?

Most practices are onboarded within two to four weeks, depending on the size of the practice and how quickly payer and system access is set up. We work within your existing practice management system, so your surgeons and front desk keep the tools they use today. See all the specialties we support.

Frequently asked questions

What is a 90-day global period in orthopedic surgery?

A 90-day global period means routine postoperative care for 90 days after major surgery is included in the surgical payment. Follow-up visits for the same surgery during that time are not billed separately. Visits for unrelated problems, planned staged procedures or a return to the operating room can be billed with the modifier that explains why the service falls outside the global payment.

How are bilateral orthopedic procedures billed?

Bilateral procedures are billed according to each payer's rules. Some expect one line with modifier 50, others expect two lines with right and left modifiers. Payment for the second side is often reduced. Because the rules differ between Medicare and commercial plans, we check the payer's policy for the procedure before the claim is sent.

Can you bill workers' compensation and auto-injury claims?

Yes. Workers' compensation and auto-injury claims are billed to the employer's carrier or the auto insurer, not the patient's health plan. They need the claim number, injury date and carrier details, and they follow state rules and fee schedules. We confirm the responsible payer at registration and follow up with the adjuster until the claim is paid.

Why are implant and brace claims denied?

Implant and brace claims are denied when the supply code or documentation is missing, when the plan required approval, or when the practice isn't enrolled as a supplier for that item. We check the payer's requirements before the item is dispensed or the surgery is billed, and attach the documentation each claim needs.

Which orthopedic services usually need prior authorization?

Advanced imaging such as MRI, joint replacement, spine surgery and some injections often need approval, depending on the plan. Requirements change between payers and over time, so we check each patient's plan before scheduling, request the approval with the supporting notes, and confirm it matches the procedure, side and location that will be billed.

Related services: eligibility and benefits verification; claim creation and submission; payment posting; denial management; provider credentialing and enrollment; accounts receivable follow-up.

Related reading: WISeR prior authorization and gold-carding; the CMS electronic prior authorization deadline.

Related specialties: physical therapy; chiropractic.