Orthopedic CPT Families Coded
Clean Claim Rate
Years in U.S. Medical Billing
Orthopedic practices without strong global period and diagnosis specificity controls commonly lose 10 to 20% of revenue to bundled post-op visits billed in error, mismatched fracture care coding, and NCCI edit denials on hardware removal. Most of it traces back to a small number of recurring coding decisions, which is exactly where specialty-specific billing pays for itself.
Where Orthopedic billing actually goes wrong
Orthopedic billing, done right
The coding decisions that cause most orthopedic denials, handled by billers who know the specialty, not just the CPT book.
Global Period Tracking
Since most joint replacement and major orthopedic procedures carry a 90-day global period, routine post-op visits during that window can't be billed separately without proper justification. We track each patient's global window closely so unrelated visits get coded correctly with modifier 24 or 79 instead of denied.
Diagnosis Specificity for Medical Necessity
Because Medicare LCDs require a structural diagnosis code rather than a generic pain code, leading with the wrong ICD-10 triggers an automatic denial regardless of clinical appropriateness. We verify diagnosis coding against current payer coverage policies before every surgical claim goes out.
Fracture Care Laterality & Encounter Coding
Since fracture codes require exact laterality along with an initial, subsequent, or sequela encounter suffix, a mismatched suffix is a common and preventable denial trigger. We code fracture care to reflect exactly where the patient sits in their treatment course.
Hardware Removal Bundling Accuracy
When hardware removal happens during a revision procedure on the same joint, it gets bundled into the revision code automatically under NCCI rules. Because reporting it separately guarantees a denial under most commercial policies, we check bundling status before submission every time.
Modifier 57 vs. 25 Precision
Modifier 57 applies to a decision-for-surgery visit ahead of a major procedure, while modifier 25 covers a separately identifiable E/M service tied to a minor one. Since payers scrutinize these modifiers heavily, we apply each only when the documentation genuinely supports a distinct service.
Prior Authorization for High-Value Procedures
Because authorization mismatches between the approved and performed procedure remain a growing denial driver, we verify authorization scope before the case is scheduled. This way, the procedure actually performed matches what the payer already approved.
Orthopedic-specific, not generalist
Billers who know cath lab bundling rules
A biller who treats every specialty the same way will bill a related post-op visit during the global period and never understand why it denied, or miss a bundled hardware removal code that guarantees rejection. Since orthopedic revenue leaks rarely sit in one place, they instead spread across global period tracking, diagnosis specificity, and NCCI bundling logic that most billers never learn to check. Ultimately, treating orthopedic surgery like standard procedural billing is exactly where the revenue disappears.
Talk to a specialistCaught before submission
Fewer denials, faster reimbursement
Orthopedic practices without strong front-end controls commonly see first-pass denial rates of 12 to 20%, driven largely by global period violations, diagnosis specificity gaps, and NCCI bundling errors on multi-code procedures. Because we catch these before the claim goes out rather than after the denial comes back, practices see cleaner claims from the first submission.
See how it works
What we hold ourselves to
Our values, in practice
Intake & Systems Review
We audit current global period tracking and diagnosis coding patterns.
Charge Capture & Coding
Procedures get coded with correct global periods, laterality, encounter type, and modifiers.
Claims Scrubbing
Claims run through payer-specific, LCD, and NCCI edits before submission.
Submission & Tracking
Clean claims go out daily, and every claim gets tracked to resolution.
Denial Management
Denials get corrected and resubmitted within payer timely-filing windows.
Global Period Monitoring
Post-op visits get flagged against each patient's global window to prevent bundled-service denials.
Reporting
Monthly reports show clean claim rate, denial trends by procedure family, and days in A/R.
Questions, answered
Orthopedic billing, answered
What Orthopedic practices ask most before switching billing partners.
What makes orthopedic billing different from other surgical specialties?
Orthopedic billing spans multiple procedure families, including arthroscopy, joint replacement, fracture care, spine surgery, and injections, each with its own coding rules, global periods, and modifier requirements. Because of this range, a biller needs fluency across several distinct rule sets rather than one standardized surgical framework.
Why do post-operative visits get denied so often in orthopedics?
Most major orthopedic procedures carry a 90-day global period, and routine post-op care during that window falls under the original surgical payment. When a related visit gets billed separately without documentation proving it's genuinely unrelated, the payer denies it automatically.
Why does diagnosis coding matter so much for joint replacement claims?
Medicare Administrative Contractors publish coverage policies that require a structural diagnosis, such as osteoarthritis codes, rather than a generic pain diagnosis as the primary code. Leading with the wrong diagnosis triggers an automatic medical necessity denial, even when the surgery itself is entirely appropriate.
How does fracture care coding differ from other orthopedic procedures?
Fracture codes require both laterality and an encounter-type suffix indicating whether the visit is initial, subsequent, or sequela treatment. Since this level of specificity doesn't appear in most other orthopedic coding, missing or mismatching the suffix is a frequent and preventable denial cause.
Can hardware removal be billed separately from a revision procedure?
No, when hardware removal happens during a revision arthroplasty at the same operative session on the same joint, NCCI bundling rules include it in the revision code automatically. Reporting it as a separate line item is one of the most common and consistently denied errors in orthopedic billing.
What denial rate should an orthopedic practice expect?
A well-run orthopedic billing operation should see a denial rate under 7%, with first-pass clean claims above 93%. Practices without strong global period and diagnosis specificity controls commonly see denial rates well above that, given how tightly payers scrutinize orthopedic claims.
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