Specialty billing
Orthopedics Billing: What Practices Should Know
Orthopedic billing crosses surgery, injections, imaging and durable medical equipment, often with workers’ compensation or auto claims in the mix.
Rules to watch
- Decision-for-surgery visits (modifier 57)
- Staged or related procedures (58, 78)
- DMEPOS billing (e.g. HCPCS L-codes for orthotics)
- Prior authorization for MRI and surgery
- Drug units and NDC reporting
What should orthopedic practices watch in billing?
Orthopedic billing revolves around surgery and everything around it. Most procedures carry a global period of 0, 10 or 90 days, and visits inside that window are usually included in the surgical fee unless a modifier shows they are unrelated or mark a new decision for surgery. Injections need both the procedure code and the drug code, with the right units. Bracing and supplies may fall under DME rules, many procedures and imaging studies need prior authorization, and workers’ compensation claims follow state rules instead of the patient’s health plan. Getting the modifier right on post-op visits and matching drug units to what was given prevents many of the common denials.
What makes it different
What makes orthopedics billing different
Codes at a glance
Common orthopedics codes and what to watch
| Service | Codes | What to watch |
|---|---|---|
| Visits in the global period | Modifier 24 (unrelated E/M), 79 (unrelated procedure) | Otherwise included in the surgical fee |
| Decision for surgery | Modifier 57 (major surgery), 25 (minor procedure) | Documentation shows the decision was made at that visit |
| Staged or return to the OR | Modifiers 58 (staged), 78 (unplanned return) | Planned vs. unplanned is documented |
| Joint injection | 20610 (major joint), 20611 (with ultrasound guidance) | Drug billed separately with HCPCS J-code units |
| Laterality | RT, LT | Required by many payers |
Related services
Services that matter most for orthopedics
FAQ
Orthopedics billing questions
Can a visit during a global period be billed?
Routine post-operative care is included in the global surgical package. Unrelated problems (modifier 24) or a return to the operating room for a complication (modifier 78) are examples of services that may be billable with the right modifier and documentation.
How are joint injections billed?
They are usually billed with the procedure code for the injection plus the HCPCS code for the drug, in the correct number of units. Some payers also require the NDC.
Coding rules change every year. The code references on this page reflect general guidance at the time of writing. Payer policies and your documentation always determine what is billable.
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