Orthopedic billing lives on the modifier. Modifier 25 on every same-day injection visit. Modifier 24, 58, 78, 79 in the global period. DME claimed in-house or given away to a vendor. The surgery is done. The injection is done. The claim is where the cycle leaks.
A patient walks in with shoulder pain. The orthopedic surgeon evaluates them, decides on a corticosteroid injection, and performs the 20610 injection in the same visit. The claim goes out as 20610 alone. The 99214 evaluation work, plus the decision-making, plus the discussion of the injection, all of it sits in the note. None of it gets billed. The visit captures 75 dollars instead of 220. Across 300 injection visits a month, the missing modifier 25 is around 525 thousand dollars a year. Walking out the door.
That is one leak. Global period management is the second. Most major orthopedic surgeries (27447 total knee, 27130 total hip, 29827 rotator cuff repair) carry a 90-day global. During that window, routine post-op visits are bundled. Unrelated E/M visits need modifier 24. Staged procedures need modifier 58. Returns to OR for complications need modifier 78. Unrelated procedures need modifier 79. Get any of these wrong and the claim denies. Most orthopedic practices miss 40 to 50 percent of legitimate modifier 24 opportunities.
DME is the third. Knee braces, walking boots, slings, custom orthotics. Most ortho practices either skip DME billing entirely or contract with outside DME vendors who capture 60 to 70 percent of the revenue and leave the rest. Done in-house with proper L-codes and documentation, DME is a 200 thousand to 400 thousand dollar annual revenue line for a busy practice. Done badly, it is a vendor's profit margin.
Workers' comp is the fourth. State fee schedules, separate authorization workflows, attorney involvement on disputed claims. Most ortho practices serve 20 to 40 percent workers' comp volume in their patient mix but treat it as an afterthought. Done correctly, WC pays at or above commercial rates. Done wrong, the claims age and the practice eventually writes them off.
These are not coding mistakes. They are workflow problems. That is the work we do.
Pull these numbers from your practice management report. The output is what your practice should be generating in modifier 25 capture, DME billing, global period management, and workers' comp.
Based on national average rates. Your real number is usually larger once anatomic modifier accuracy, NCCI edits, and aged AR are included. The 48 hour audit gives you the line by line breakdown from your own data.
What a percentage based billing vendor delivers versus what a managed department delivers.
Sixty plus codes in orthopedic scope. Search by number or filter by category.
A managed department, not a claim submission service. Every function below runs under the same operations head, with the same KPIs, reporting into Apex.
| Function | What Quilven runs | What typical vendors do |
|---|---|---|
| Modifier 25 on injections | Same-day E/M plus injection audited on every claim. 99214+modifier 25+20610 captures ~$220 per visit. | Modifier 25 missing. Only the injection bills. E/M denied as bundled. |
| Global period E/M | Global periods tracked at scheduling. Modifier 24, 58, 78, 79 applied based on clinical scenario. | Post-op E/M denied. Practice writes the visit off as bundled. |
| DME billing | L-codes billed in-house. Standard Written Orders documented. PTAN maintained with DME MAC. | Outside vendor takes the DME revenue. Practice gets 30 to 40 percent. |
| Workers' compensation | State-specific fee schedules. Prior auth tracked. Attorney correspondence managed. IME coordination. | WC treated as commercial. Wrong fee schedule. Disputed claims drift. |
| Anatomic modifiers | RT, LT, F1-F5 (fingers), T1-T5 (toes), 50 (bilateral) applied to every procedure code by rule. | Inconsistent. Specificity denials accepted. |
| Surgical modifier 58/78/79 | Coded based on documented clinical scenario. Staged vs complication vs unrelated distinguished. | Default modifier 78 or no modifier. Return-to-OR claims denied as duplicate. |
| Aged AR on procedures | High-dollar surgical claims over 90 days worked first. Appeals to round three or four. | Aged claims written off. First appeal sent, then silence. |
| Credentialing + ASC privileging | Payer credentialing plus hospital plus ASC privileging on a live master sheet. Target 90 days payer billable. | Payers tracked. Hospital and ASC privileging treated as side tasks. |
Eight questions. No email required.
The questions practice administrators actually ask before signing with a billing company.
Three fields. We get back to you the same business day. The 48 hour audit gives you a line by line breakdown of what is recoverable from your last 90 days of claims, by CPT code and by payer.
No commitment. No pitch deck. If your cycle is clean you get outside confirmation. If it is not you get a real number from your own data.
Where do we send the findings.
A senior member of the team will reach out within the next business hour. Watch your phone.
Enter an orthopedic procedure code and a surgery date. See the global period, the date it expires, and the modifier rules during the window. Useful for billers and surgical schedulers.
Line by line, by code, by payer, by month. Specific to orthopedics. Specific to your practice.