Orthopedic practices focus on diagnosing, treating, and managing conditions related to the musculoskeletal system — including bones, joints, ligaments, tendons, and muscles. Given the complexity of procedures and the high volume of services, orthopedic medical billing requires precision, attention to detail, and a strong understanding of coding guidelines.
In this blog, we’ll explore the key services included in orthopedic billing and highlight common mistakes that can lead to denials, delays, or revenue loss.
What Services Are Included in Orthopedic Medical Billing?
Orthopedic medical billing covers a wide array of services, ranging from evaluation and diagnosis to surgical procedures and post-operative care. Here are the primary categories:
1. Evaluation and Management (E/M) Services
These are routine office or hospital visits where the orthopedic provider evaluates a patient’s condition, creates a treatment plan, or follows up on previous care.
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CPT Codes: 99202–99215 (Outpatient visits), 99221–99223 (Initial hospital care), etc.
2. Diagnostic Imaging and Tests
Orthopedic practices often rely on imaging to diagnose conditions:
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X-rays (e.g., CPT 73030 – X-ray of shoulder)
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MRI (e.g., CPT 73721 – MRI of the knee)
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CT scans and ultrasounds
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Bone density tests
3. Fracture Care
Orthopedists treat a wide variety of bone injuries:
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Closed or open reduction
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Casting or splinting
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Surgical treatment of fractures
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CPT examples: 26600 (Closed treatment of metacarpal fracture), 27506 (Open treatment of femoral fracture)
4. Joint Procedures
This includes both non-surgical and surgical joint treatments:
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Arthrocentesis (joint aspiration)
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Joint injections (e.g., for pain relief or anti-inflammatory treatment)
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Arthroscopy (minimally invasive joint surgery)
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Joint replacement (e.g., total hip or knee replacement)
5. Soft Tissue and Ligament Repairs
Orthopedic billing also includes:
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Tendon repairs (e.g., rotator cuff)
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Ligament reconstructions (e.g., ACL repair)
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Carpal tunnel release surgery
6. Spinal Procedures
Spinal care is often part of orthopedic billing, including:
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Spinal fusion
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Laminectomy
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Vertebroplasty
7. Durable Medical Equipment (DME) and Supplies
Orthopedic practices may bill for braces, slings, orthotics, and other support equipment.
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Use HCPCS codes for billing DME
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Common codes include L1832 (knee brace), L1902 (ankle support), etc.
What Are Some Common Mistakes Made in Orthopedic Medical Billing?
Orthopedic billing is prone to errors due to its procedural complexity. Here are some of the most frequent mistakes:
1. Incorrect Use of Modifiers
Modifiers are essential for clarifying procedures, especially when multiple services are performed. Common issues include:
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Failing to use Modifier 59 (distinct procedural service)
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Misusing Modifier 25 (significant E/M service on the same day as a procedure)
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Not using RT/LT (right/left) modifiers where applicable
2. Unbundling Services
Some procedures are already bundled under a single CPT code. Billing them separately (unbundling) can lead to denials and even compliance issues.
3. Coding for the Wrong Side or Limb
Orthopedics often involves bilateral body parts. Failing to specify laterality (e.g., left vs. right knee) is a common oversight that results in claim rejections.
4. Inaccurate or Missing Documentation
Proper documentation is key to supporting billed procedures. Common documentation issues include:
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Missing operative notes
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Lack of justification for medical necessity
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Failure to link diagnosis codes to the correct procedures
5. Overlooking Pre-authorization Requirements
Many orthopedic services, especially surgeries and imaging, require prior authorization. Skipping this step can result in claim denials or non-payment.
6. Improper Use of Global Period Rules
Post-operative care is typically included in the global surgical package. Billing separately for services during the global period without proper modifiers (e.g., Modifier 24 for unrelated E/M during post-op) can lead to overpayments and audits.
7. Failure to Keep Up with Coding Changes
CPT and ICD-10 codes are updated annually. Using outdated codes is a leading cause of claim denials.
Final Thoughts
Orthopedic medical billing is a nuanced field that involves a wide range of services and detailed coding knowledge. From joint replacements to spinal procedures and fracture care, orthopedic billing must be done with precision and compliance in mind.
Avoiding common mistakes like incorrect modifiers, poor documentation, and failure to obtain authorizations can make a significant difference in your revenue cycle. Whether you’re a solo practitioner or part of a larger orthopedic group, having an experienced billing team or outsourcing to a specialized billing service can help you maximize reimbursement and minimize errors.
Looking for professional orthopedic billing services? We specialize in accurate coding, clean claims, and faster payments. Contact us today to streamline your orthopedic billing process!
