Orthopedic Billing Services for Surgeon Groups and Joint Centers

The Codes an Orthopedic Group Bills Most

Modifiers That Matter

Payer Rules to Know

Top Denials in Orthopedic Billing Services for Surgeon Groups and Joint Centers

What Does Orthopedic Billing Cover?

Orthopedic billing covers the professional claim for surgeons and their clinics: new patient visits, imaging, injections, casting, surgery and the follow-up visits that come after it. The claim goes on the CMS-1500. The hospital bills its own facility claim for the same operation on the UB-04.

One total knee replacement can produce a surgeon claim, an assistant surgeon claim, an anesthesia claim, an implant charge on the facility side and three months of follow-up visits that are meant to be free. For the facility side, see hospital and facility billing. This page covers the surgeon and clinic side.

What Is Included in the Global Period for a Total Knee Replacement?

A total knee replacement, CPT 27447, has a 90-day global period. The CMS Physician Fee Schedule file RVU26D gives 27447 and total hip replacement 27130 a global indicator of 090, which CMS calls a major surgery. The file splits 27447 payment into 10 percent preoperative, 69 percent intraoperative and 21 percent postoperative work.

The Medicare Claims Processing Manual, Chapter 12, section 40.1, counts one day before surgery, the day of surgery and the 90 days after. CMS's example: surgery on January 5 runs January 4 to April 5. The package applies in any setting: hospital, surgery center or office.

Chapter 12 says the package includes related visits from the day before surgery, usual intraoperative work, complications that do not need another trip to the operating room, related follow-up, the surgeon's pain management, most supplies and routine care such as removing sutures, drains and casts. It leaves out diagnostic tests and imaging, unrelated visits, treatment of a different condition, staged or clearly distinct procedures, and complications that need a return to the operating room.

How Do We Bill an Office Visit During the Global Period?

Bill it with modifier 24 only when the visit is unrelated to the surgery, and bill nothing for routine recovery. Chapter 12, section 40.4, tells Medicare contractors to deny postoperative visits that carry no modifier, and says 24 is for services absolutely unrelated to the surgery, never for the surgeon's own medical management after it. Section 40.2 accepts a diagnosis code that clearly shows the visit was unrelated as documentation.

A new shoulder complaint in a knee patient is the kind of visit that can qualify. Knee swelling on day 20 is recovery work. Routine follow-up is tracked with CPT 99024, which RVU26D gives status B, always bundled into other payment.

The other global modifiers answer different questions:

• Modifier 25: a significant, separately identifiable visit on the day of a minor procedure. The NCCI Policy Manual (the National Correct Coding Initiative manual, whose edits block code pairs billed together) says it does not require a different diagnosis, but the decision to do the minor procedure is not billable.
• Modifier 57: the visit that produces the decision for major surgery, on the day before or the day of it. Chapter 12 says to use 57, not 25, and never on minor procedures.
• Modifier 58: a staged or related procedure in the postoperative period. A new period begins with it.
• Modifier 78: an unplanned return to the operating room for a related procedure. Medicare pays the intraoperative portion of the code.
• Modifier 79: an unrelated procedure by the same physician. A new period begins with it.
• Modifiers 54 and 55: surgical care only, or postoperative care only, when care is transferred. Both claims show the dates, and the transfer agreement stays in the chart.

NCCI names 24, 25, 57, 58, 78 and 79 as global surgery modifiers that can bypass an edit, and says 22, 76 and 77 never do. Medicare also uses modifier FT for an unrelated evaluation and management visit in a global period, and requires it on critical care unrelated to the surgery.

How Do We Bill Fracture Care and Casting?

A fracture treatment code already includes the first cast, splint or strapping, so you do not bill a casting code on top of it. NCCI Chapter IV, section G, says codes for closed, percutaneous or open treatment of fractures and dislocations include casts, splints and strapping, and the casting codes are not reported separately. The same holds when the physician applies the first cast and then takes over follow-up. Removal codes 29700 through 29750 apply only when someone else applied the cast.

Fracture treatment codes carry a 90-day global period in RVU26D, such as 25605 for a wrist fracture and 27758 for a tibia fracture. Casting codes carry 000. A visit billed with a casting code needs modifier 25 and must be significant and separately identifiable, because the decision to cast belongs to the casting code. The October 2026 HCPCS file lists Q4010 as a fiberglass short arm cast for an adult aged 11 or older and Q4050 for unlisted cast supplies.

How Do Joint Injections and Arthroscopy Get Coded?

A large joint injection, CPT 20610, is billed once per joint. The NCCI Policy Manual says the 20600 to 20611 family counts one unit per joint and its surrounding bursae, so a shoulder with two bursae injected is still one unit.

20610 carries a 000 global period in RVU26D. The drug is its own HCPCS Level II line, and for a per dose hyaluronan code such as J7321 NCCI allows one unit per knee joint however much is injected. A same-day visit needs modifier 25 and must stand apart from the decision to inject.

Arthroscopy has its own NCCI rules. Surgical arthroscopy includes diagnostic arthroscopy, so only the surgical code is reported. If it converts to an open procedure, only the open code is reported. Knee codes 29880 and 29881 already include cartilage shaving, and G0289 can be added only for a loose or foreign body removed from a different compartment. Imaging sits outside the package: CPT 73721 has an XXX global indicator and a professional and technical split, so a physician who only reads the study bills modifier 26.

How Do RT, LT, Modifier 50 and the Finger and Toe Modifiers Work?

Medicare wants a bilateral procedure on one line with modifier 50 and one unit, unless the descriptor already says bilateral. Chapter 12, section 40.7, states this and notes it differs from CPT, which shows two lines. Code 27395, whose descriptor says bilateral, is billed without 50. Medicare pays a bilateral surgery at 150 percent of the fee schedule amount when the bilateral indicator is 1, as it is on 27447 and 27130.

An ASC does the opposite. NCCI says the modifier 50 rule does not apply to an ambulatory surgical center (ASC), which reports each side on its own line with one unit and LT or RT. Practitioners and outpatient hospitals use 50. Several procedures on one day follow a ranking rule: under the standard indicator 2 the highest-valued procedure pays 100 percent and the second through fifth pay 50 percent, and the lesser procedures carry modifier 51.

Digits have their own modifiers. NCCI says fingers use FA and F1 through F9 and toes use TA and T1 through T9. The October 2026 HCPCS file defines FA as the left thumb, F5 as the right thumb, TA as the left great toe and T5 as the right great toe. See the pages for modifier 50 and LT and RT.

Do Implants Get Billed Separately in an ASC, and What About DME?

Not under Medicare. The Claims Processing Manual, Chapter 14, section 10.4, says payment for implantable prosthetic devices without OPPS pass-through status is included in the ASC payment, and an ASC may not bill them separately. The same applies to implantable DME. Implant payment on commercial plans is set by each contract, so read it before the first case.

Braces are different. Chapter 14 says leg, arm, back and neck braces are covered under Part B but are not in the ASC payment, so a center that supplies them is a supplier with its own supplier number and bills the DME MAC where applicable. The October 2026 HCPCS file lists knee orthoses such as L1833 and wrist orthoses such as L3908. On the facility side it also lists C1776 for an implantable joint device and C1713 for an implantable anchor or screw. Whether a payer wants those lines depends on its contract.

Which Orthopedic Procedures Commonly Need Prior Authorization?

There is no national list. Each payer publishes its own and changes it, so check the current list before scheduling and keep the approval number on the case. Our prior authorization service handles this for each payer.

In Original Medicare, the WISeR Model (Wasteful and Inappropriate Service Reduction) runs from January 1, 2026 to December 31, 2031 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. Its services include knee arthroscopy for knee osteoarthritis. A provider can request prior authorization or let the claim go through medical review before payment. WISeR does not apply to Medicare Advantage.

The Transforming Episode Accountability Model (TEAM) is mandatory for selected hospitals from January 1, 2026 to December 31, 2030 and covers lower extremity joint replacement, surgical hip and femur fracture treatment and spinal fusion, among others. It holds the hospital accountable from surgery through 30 days after discharge.

How Do Medicare and Commercial Payer Rules Differ for Orthopedic Claims?

Medicare follows Chapter 12. UnitedHealthcare's commercial Global Days Policy, number 2026R0005F, follows CMS global day values and CMS rules on what the package includes. The differences are in the details.

UnitedHealthcare bundles follow-up by anyone with the same specialty, group and tax identification number. It pays modifier 78 at the CMS intraoperative percentage, generally 60 to 84 percent, and starts no new global period. It does not require two different diagnosis codes to pay modifier 25. Medicare timely filing is one calendar year from the date of service under 42 CFR 424.44, while commercial limits come from each contract. See the Medicare guide and UnitedHealthcare guide.

Does the No Surprises Act Apply to Orthopedic Claims?

Yes, for out-of-network orthopedists at in-network facilities and in emergencies. Under 45 CFR 149.420, a nonparticipating provider at a participating facility cannot bill the patient above in-network cost sharing unless the provider gives written notice and gets consent.

Surgeons can use notice and consent for scheduled care, with notice at least 72 hours before the service when the appointment is made 72 hours or more ahead. The exception excludes assistant surgeons and other ancillary services, and services needed because of unforeseen, urgent medical needs. A trauma call in the emergency department falls under 45 CFR 149.410. If the plan underpays, the parties go to open negotiation and then federal IDR. We handle both from first notice to final payment.

What Are the Most Common Orthopedic Denials and How Are They Worked?

Most are global period denials. CO-97 on a postoperative visit means the payer treats it as part of the package. Check the date against the 90 days, then add 24, 25 or 57 only if the chart supports it. The denials table on this page lists the others. Denials are worked within 48 hours, and repeat causes such as a missing modifier are fixed at charge entry.

How We Handle Orthopedic Billing

We code each case from the operative note and apply the global rules before the claim leaves. Claims are sent within 24 hours of charge entry, and our clean claim rate is 95%.

To talk through your caseload and payers, book a call.