Orthopedic billing is
a modifier discipline.
Orthopedics is the one specialty on this list that does not run on infusion machinery. Its revenue leaks somewhere else: inside global periods, in equipment nobody enrolled to bill, in a work comp queue ageing on a different clock, and in claims that paid, just not at the contracted rate.
The money leaks inside the ninety days, not outside them
A ten or ninety day global period absorbs related care into the surgical fee. Unrelated care inside that window is payable. So is a staged procedure, so is an unplanned return to theatre, so is an unrelated procedure on the other knee. None of it is payable without the right modifier, and the difference between 58, 78 and 79 is not a nuance, it is whether the claim pays at all. Practices that have never tracked the window systematically are usually surprised by what is sitting in it.
- Global period tracked from the surgical date so encounters inside it get examined
- Modifier 24 applied to unrelated evaluation and management inside the window
- Modifiers 58, 78 and 79 distinguished rather than used interchangeably
- Modifier 25 supported by documentation when a visit and a procedure share a day
A different payer, a different clock and a different form
Workers compensation and personal injury do not behave like commercial claims. State fee schedules, jurisdiction-specific filing, FROI and SROI reporting, authorization tied to a claim number and an adjuster rather than a member ID, and timelines that run months past anything a commercial A/R report is built to surface. Worked in the same queue as everything else, these age quietly and get written off as uncollectable when they were only slow.
- Work comp and personal injury worked as their own queue on their own ageing
- Jurisdiction filing rules applied per state rather than per habit
- Claim number and adjuster verified before submission, because a wrong one is unworkable
- Liens and settlements tracked to resolution rather than closed at write-off
The brace you dispensed needs an enrolment you may not have
Dispensing braces, boots and bone growth stimulators from the office is a separate billing arrangement with its own supplier enrolment, its own documentation standard and its own audit exposure. The usual sequence is that a practice dispenses for months, the claims deny in a batch, and the enrolment gap turns out to predate the inventory. The documentation standard is stricter than the surgical one, which catches people out.
- Supplier enrolment and accreditation confirmed before equipment goes out the door
- Documentation built to the equipment standard rather than the surgical one
- Rental against purchase determined per item and per payer rather than defaulted
The one place orthopedics behaves like oncology
Hyaluronic acid injections are bought by the practice and billed to the payer, which puts them squarely in buy-and-bill territory: brand-specific coverage, prior authorization, frequency limits counted in months, and a unit count that has to match what was in the syringe. Plans cover particular brands rather than the class, and they change which. This is the part of orthopedic billing that runs on the same machinery as our lead specialty.
- Brand coverage confirmed per payer, because plans cover products rather than the class
- Frequency limits checked against the last injection date before the appointment
- Units matched to the product supplied, with wastage reported where it applies
A correctly coded claim can still be paid wrong
Bilateral procedures, multiple procedures in one session and add-on codes all carry payment reduction rules that vary by payer and by code. The claim goes out clean, comes back paid, and nobody checks the amount against the contract. Underpayment never appears in a denial report. It appears only if somebody is comparing remittance to expected rate, and in most practices nobody is.
- Bilateral and side indicators applied consistently rather than interchangeably
- Multiple-procedure reductions checked against the contract rather than accepted
- Remittance compared to expected contract rate, not just paid against billed
- Implants and hardware handled per site of service, which prices them differently
Timed codes are counted in minutes, and the note has to show them
In-house physical therapy converts documented treatment minutes into billable units under counting rules that are unforgiving about what the note actually says. A note recording what was done but not how long turns payable therapy into unpayable therapy, and the therapist has already spent the afternoon.
- Treatment minutes documented so timed units can be substantiated
- Timed and untimed codes distinguished before submission
- Supervision arrangement matched to who actually delivered the care
This is what we watch for. How the engagement runs is a separate question.
Before any of it applies to your practice we read your aged A/R and the last quarter of remittance advice, and you get the findings in writing including what we think is not worth chasing. You keep your practice management system, your payer contracts and your NPI throughout.