Orthopedics Medical Billing Services

Orthopedics mixes high-dollar surgery with in-office imaging, injections and bracing, and almost every one of those has a gate in front of it. The denials that hurt are not coding mistakes discovered later — they are permissions that were never obtained and post-operative rules nobody tracked.

Prior authorization is the number one orthopedic denial

Advanced imaging, most surgery, many injections and a large share of durable medical equipment require authorization, and commercial plans increasingly route musculoskeletal decisions through a specialty benefit manager rather than deciding in-house. Worse, many payers require documented failed conservative treatment first — a specified course of physical therapy, anti-inflammatories or activity modification — before they will approve an MRI or a procedure.

That means the authorization can fail for a reason that has nothing to do with billing: the conservative-care history was not documented in a form the reviewer accepts. We verify benefits and obtain authorization before the service, track the authorized code against what is actually performed, and flag when the documentation will not support the request before it is submitted rather than after it is denied. Verification and authorization work are included at no additional charge. See prior authorization delays.

Global periods, and the modifiers that survive them

Major orthopedic surgery carries a 90-day global period and minor procedures typically 10 or zero days. Inside that window, routine post-operative care is already paid and is not separately billable. What is billable is anything genuinely outside routine follow-up, and each situation has its own modifier.

An evaluation for an unrelated problem during the global period takes modifier 24. A significant, separately identifiable evaluation on the same day as a minor procedure takes modifier 25, while the decision for major surgery takes modifier 57. A staged or related procedure takes 58, an unplanned return to the operating room takes 78, and a completely unrelated procedure during the period takes 79. Get one of these wrong and the claim denies as included in the global surgery — and the appeal requires an operative note nobody wants to dig out three months later.

Bundling, laterality and multiple procedures

Arthroscopy in particular is a minefield: procedures performed in the same compartment during the same session are frequently bundled by correct-coding edits, and only some of those edits permit a modifier override. Multiple procedures in one session trigger reduction rules. Laterality has to be reported correctly, and a claim missing left or right on a paired body part is a rejection before it reaches adjudication.

We code from the operative report rather than from a scheduled procedure list, because what was scheduled and what was performed diverge often in orthopedics. See coding and audits.

DME and bracing: usually the biggest surprise

Practices that dispense braces, walkers, boots and other equipment often assume they can bill it like any other service. They cannot. Supplying durable medical equipment generally requires separate supplier enrollment, a written order meeting specific content requirements, documentation of medical necessity, and correct HCPCS coding with the modifiers that indicate purchase, rental and that coverage requirements were met.

Practices that dispense without the enrollment in place find out months later, when the claims deny and the equipment is long gone. We check the enrollment first, and handle the enrollment itself as part of credentialing, included at no extra charge.

Injections, drugs and wastage

An injection generates two charges: the administration and the drug. The drug is reported by its own code in the correct billing units, which are almost never the same as the vial size, and unit errors here produce both denials and recoupments. Where a single-dose vial is partially used, the discarded portion is separately reportable with the wastage modifier and appropriate documentation — money most practices never bill at all.

Viscosupplementation and similar high-cost injectables usually require authorization on top of that, with their own conservative-treatment prerequisites.

In-office imaging and where it was performed

A practice that owns its X-ray equipment and employs the technologist bills globally. A physician interpreting a study performed at a hospital or imaging center bills the professional component only. Practices working across an office and a surgery center or hospital need this mapped by location, and it quietly breaks whenever a physician adds a new facility.

Claims go out within 24 hours, denials are worked within 48 hours, and insurance aging is worked at 25 to 30 days. On surgical claims that matters — a denied high-dollar claim discovered at 90 days is a serious cash-flow event. See A/R follow-up.

Why practices choose Synergy for orthopedics billing

A 98% clean-claim rate, claims submitted within 24 hours, denials worked within 48 hours, free provider credentialing, and transparent monthly reporting — with a 30-day free trial and a 90-day money-back guarantee.

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