Question 1

What is a global period in orthopedic billing?

Accepted Answer

A global period is the span after a procedure during which routine follow up is included in the surgeon's payment. Major surgeries such as total knee and hip replacement carry 90 days, and many minor procedures carry 0 or 10 days. Visits inside the window are not billed separately unless they are unrelated and reported with a modifier such as 24. We log included visits with 99024 so none are missed or billed by mistake.

Question 2

When do you use modifier 57 and modifier 25?

Accepted Answer

Modifier 57 goes on an E/M visit that leads to the decision for a major procedure, on the day before or the day of surgery. Modifier 25 goes on a significant and separately identifiable E/M visit on the same day as a procedure, such as an exam and a joint injection. Both need documentation that shows the visit stands apart from the procedure.

Question 3

What is the difference between modifiers 80, 82 and AS for an assistant at surgery?

Accepted Answer

Modifiers 80 and 82 report an assistant surgeon who is a physician, with 82 used when a qualified resident was not available in a teaching hospital, while AS reports a physician assistant, nurse practitioner or clinical nurse specialist. Medicare pays an assistant surgeon billing 80 or 82 16 percent of the fee schedule amount, and an AS assistant 85 percent of that, or 13.6 percent. Payment also depends on the assistant at surgery indicator for each code, and other payers set their own rules, so we check both before the claim goes out.

Question 4

Does Medicare cover hyaluronic acid injections for knee osteoarthritis?

Accepted Answer

Sometimes. Coverage is set by local Medicare contractor policies rather than one national rule, so it depends on your jurisdiction. Palmetto GBA's policy (L39260), for example, requires x-ray evidence of knee osteoarthritis, at least 3 months of failed conservative treatment, failure of or a reason to avoid a steroid injection, and at least 6 months between injection series. We read the policy for your contractor and check the notes before billing the J code.

Question 5

Does Medicare cover knee arthroscopy for osteoarthritis?

Accepted Answer

Usually not. National Coverage Determination 150.9 excludes arthroscopic lavage alone, debridement when knee pain is the only symptom, and debridement in severe osteoarthritis, Outerbridge grade III or IV. Contractors may cover debridement in milder disease with mechanical symptoms such as locking. CMS's WISeR model, running since January 1, 2026 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, also adds prior authorization review for this service, so we document symptoms and imaging first.

Question 6

How long do I have to appeal a denied orthopedic claim?

Accepted Answer

For Medicare, you have 120 days from receipt of the initial determination to request a redetermination, and receipt is presumed 5 days after the notice date. Reconsideration is the next level, with 180 days to file. A clerical error such as a missing modifier can sometimes be fixed through a Medicare reopening instead. Commercial plans set their own limits in the contract and denial letter, so we log the deadline on every denial.

Question 7

How did the 2026 Medicare efficiency adjustment affect orthopedic surgery payments?

Accepted Answer

Starting January 1, 2026, CMS cut the work values of most non-time-based services by 2.5 percent, which reaches many surgical codes. E/M visits and services on the Medicare telehealth list are excluded. A one-time 2.5 percent conversion factor increase for 2026 offset part of the cut, and facility based services also saw a change in indirect practice expense. The net effect differs by code and site, so we model your top procedures against the 2026 fee schedule.

Question 8

Will Medicare cut payment for modifier 25 visits on procedure days in 2027?

Accepted Answer

That is only a proposal for now. The CY2027 physician fee schedule proposed rule would pay the higher paid service in full and the other at 50 percent when an office visit and a procedure with a 0, 10 or 90 day global period are billed by the same physician on the same day. Comments closed September 14, 2026, and the rule is not final. We will update our modifier 25 reviews once CMS publishes the final rule.

Question 9

Can Medicare patients have total knee or hip replacement as outpatient surgery?

Accepted Answer

Yes. Medicare removed total knee replacement (27447) from its inpatient only list in 2018 and total hip replacement (27130) in 2020, and both are now on the ambulatory surgery center covered procedures list, knee since 2020 and hip since 2021. CMS is also phasing out the inpatient only list over three years, starting with 285 mostly musculoskeletal procedures in 2026. Site of service is a clinical decision, and the surgeon's 90 day global period still applies.

Question 10

When do you use modifier 62 for co-surgeons in orthopedic spine surgery?

Accepted Answer

Use modifier 62 when two surgeons each perform a distinct part of the same procedure in one session and neither acts as an assistant, such as an approach surgeon and a spine surgeon. Both report the same code with modifier 62, and Medicare pays each 62.5 percent of the fee schedule amount when the code's co-surgery indicator allows it. Each surgeon documents their part in the operative note. Some payers do not allow co-surgery, so we check the policy first.

Question 11

How do you bill when another doctor takes over post operative care, modifiers 54 and 55?

Accepted Answer

The operating surgeon bills with modifier 54 for surgical care only, and the physician taking over follow up bills with modifier 55 for postoperative management only. Medicare divides the global payment using the fee schedule percentages for pre, intra and postoperative care, and expects a written transfer of care agreement with the date care changed hands. The receiving physician must see the patient at least once before billing. Physicians in the same group practice generally do not use these modifiers.

Question 12

How much does orthopedic billing cost?

Accepted Answer

Most billing companies charge a percentage of the revenue they collect, and published industry ranges commonly fall between 4 and 8 percent, with some offering flat monthly fees. The rate depends on claim volume, payer mix, how much work is included, such as coding, authorization and credentialing, and the state of your accounts receivable. We quote after reviewing your volume and payer mix.

Question 13

What is the difference between modifier 58 and modifier 78?

Accepted Answer

Modifier 58 is for a planned, staged or more extensive procedure related to the first one, during the global period. Modifier 78 is for an unplanned return to the operating room for a related complication, and payers generally pay only the intraoperative portion without starting a new global period. Under Medicare's global surgery rules, a complication that does not need the operating room is included in the surgeon's payment. Commercial payers set their own rules, so we check each policy.

Question 14

How do you bill fracture care correctly?

Accepted Answer

Fracture care codes include the initial evaluation, the reduction, the first cast or splint and follow up inside the global period. We pick the code from the type of treatment: closed, percutaneous or open. We also match the ICD-10 seventh character to the stage of care, using A for active treatment, D for routine healing, G, K or P for delayed healing, nonunion or malunion, and S for late effects, so the diagnosis agrees with the care.

Question 15

What are the finger and toe modifiers in orthopedic billing?

Accepted Answer

They are twenty HCPCS modifiers that name the exact digit treated. FA and F1 to F9 are for fingers and thumbs, and TA and T1 to T9 are for toes, with separate modifiers for the left and right side. The CMS NCCI manual says many finger and toe procedures have a unit limit of one because of them, so each digit is billed on its own line. Some payers want modifier 59 or 51 as well, and a few reject them, so we check each plan.

Question 16

How is a bilateral orthopedic procedure billed?

Accepted Answer

It depends on the code. For codes with a bilateral surgery indicator of 1, Medicare wants one line with modifier 50 and one unit, and it pays 150 percent of the single fee. Codes with an indicator of 0 or 2 get no 150 percent adjustment, and billing two units where modifier 50 is required can trigger a unit limit denial. Other payers may ask for RT and LT on two lines instead, so we load the rule for each one.

Question 17

Does the TEAM model affect orthopedic surgeons?

Accepted Answer

TEAM, the Transforming Episode Accountability Model, began on January 1, 2026 and is mandatory for acute care hospitals in selected areas. Lower extremity joint replacement is one of its episodes, along with surgical hip and femur fracture and spinal fusion. The hospital carries the spending risk for the 30 days after discharge. Surgeons are still paid fee for service, and physician groups can take part in gainsharing as TEAM collaborators. For billing, the practical points are accurate dates and codes on professional claims and a review of any gainsharing agreement.

Question 18

Why are arthroscopy claims bundled or denied?

Accepted Answer

Payers apply NCCI edits that combine many arthroscopic codes performed in the same joint, so the most extensive code is paid and the others are bundled. In the knee, 29881 already includes cartilage shaving and 29880 covers both menisci. Modifier 59 or XS can separate work done in a distinct area, but only when the operative note supports it. We code from the note and appeal when the record is clear.

Question 19

Do you handle prior authorization for MRI and joint replacement?

Accepted Answer

Yes. Many plans require approval for advanced imaging such as MRI and for elective joint replacement, while traditional Medicare generally does not require it for joint replacement and Medicare Advantage plans often do. For plans covered by the federal prior authorization rule (CMS-0057-F), payers must decide within 72 hours for urgent requests and 7 calendar days for standard ones. We request approval when the case is scheduled and track it to a decision.

Question 20

Can you bill workers compensation and personal injury cases?

Accepted Answer

Yes. Workers compensation follows state fee schedules, carrier or adjuster approval, specific forms and set filing windows. Personal injury and auto cases may be paid through medical payments coverage or a letter of protection that pays on settlement. We set up each case type on its own track because the rules, the forms and the timelines differ.

Question 21

How do you bill implants, injections and braces?

Accepted Answer

In a hospital, the facility bills implant costs. In a surgery center, we match the implant log and invoice to the facility claim so the device is reported. In the office, we bill hyaluronic acid injections with the product's J code, units and lot number, plus the administration code, and braces with L codes. We also check each payer's coverage policy, because many plans limit these items.

Question 22

What do you need from us to get started?

Accepted Answer

EHR or practice management access, your payer list and fee schedules, your recent denial reports, and a list of surgeons and sites. We usually begin with an audit of surgical claims and open global periods, because that is where the fastest gains are.

Question 23

What should an orthopedic practice look for in a billing company?

Accepted Answer

Look for coders who work in orthopedics every day, a clear process for global periods and fracture care, prior authorization handled before surgery, and a monthly report that explains why claims were denied and what changed. Ask who owns each denial, how fast claims go out after a case, and whether you keep access to your own data. DrCareMSO assigns certified coders to each practice and shares denial and collection reports every month.

Question 24

How do orthopedic billing services help with knee and hip replacement claims?

Accepted Answer

Joint replacement claims carry high payment and strict rules. A billing team confirms coverage and approval before the date is booked, sets the side and procedure from the operative note, matches the implant log to the claim, opens the 90 day global period, and tracks every follow up visit inside it. That is how revenue from knee and hip replacement stays intact instead of leaking through downcodes and bundling denials.

Question 25

Can you handle billing for sports medicine, hand, foot and ankle, and spine practices?

Accepted Answer

Yes. We bill for general orthopedics and for sports medicine, hand and upper extremity, foot and ankle, spine, trauma and joint reconstruction groups. Each subspecialty has its own procedures, authorization rules and denial patterns, so we set up payer rules and coding checks for the services your surgeons perform most.

Question 26

How do you reduce denials for orthopedic claims?

Accepted Answer

We stop denials before the claim is sent. Coverage and authorization are checked ahead of the visit, the operative note is matched to the procedure and diagnosis, bundling and global period rules are applied at charge entry, and every rejection is corrected the same week. Each month we group the denials that still happen by cause and fix the source, so the same problem does not return.

Question 27

Can you take over orthopedic billing from another company without disrupting cash flow?

Accepted Answer

Yes. We review your open accounts receivable, set up the clearinghouse and payer enrollment files, load your fee schedules and payer rules, and begin billing new charges while we work the older claims in parallel. The goal is to keep payments moving through the change, with a clear list of what is open and who is working it.

Question 28

How do I choose a orthopedic billing company?

Accepted Answer

Look for coders trained in orthopedic claims, a plan for authorizations before the case or study, denial follow-up that continues until the claim is paid or appealed, and a monthly report you can read without a billing background. Ask who owns the payer deposits (they should go to your account) and ask to see a sample report before you sign.

Question 29

Is outsourcing billing a good fit for a small orthopedic practice?

Accepted Answer

Often yes. A small practice carries the same payer rules as a large one, but with fewer staff to track knee and hip replacement, fracture care and arthroscopy. Outsourcing replaces a part time billing hire with a team that works the claims every day. The right choice depends on your volume and how much time your staff spend on denials today, and we can look at your numbers with you on the first call.

Question 30

What reports will I receive from a orthopedic billing company?

Accepted Answer

We send a monthly report that shows what was billed and paid, what is still open and why denials happened, grouped by cause so the source can be fixed. You can also ask for the payer mix and the oldest unpaid claims. Report details are agreed when you start, so you only get what you will use.

Orthopedic medical billing, from fracture care to joint replacement

What does an orthopedic billing company do?

Where orthopedic claims lose money

Fracture claims that do not match the care

Arthroscopy claims that get bundled

Implants, injections and braces left unbilled

Authorization, workers compensation and injury cases

What we bill in every orthopedic claim

Joint replacement

Arthroscopy

Fracture and dislocation care

Injections and office procedures

Imaging and bracing

Every finger and toe is billed on its own line

Right and left side

Bilateral procedures

Fingers and toes

How we run orthopedic RCM

Verify coverage and authorization rules

Capture the case at the source

Code with the global period in mind

Track follow up inside the window

Submit, work denials and fix the cause

Why orthopedic practices choose DrCareMSO

Certified coders for orthopedic claims

Approvals before the case is scheduled

Every denial worked to payment

A monthly report in plain language

One orthopedic group, three leaks, fixed

Before

After

Orthopedic billing questions

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