Orthopedic billing

Orthopedic Medical Billing and Revenue Cycle Management 

Quilven runs the revenue cycle for independent orthopedic practices as an outsourced billing department. Three things decide what an orthopedic practice collects: whether the global surgical package and its modifiers are handled correctly, whether workers' compensation is billed as the separate world it is, and whether in-office ancillaries are run cleanly enough to be worth having. We are paid a percentage of what we collect, month to month, no setup fee and no minimum.

Section 3

Can we bill an office visit during the global period?

It depends on the length of the global period and on the relationship between today's visit and the surgery. Routine post-operative care is bundled and not separately billable. An unrelated evaluation during the period takes modifier 24. A significant, separately identifiable visit on the same day as a minor procedure takes modifier 25. The visit at which the decision for major surgery is made takes modifier 57.

Where a code's global period comes from

Every procedure code carries a global surgery indicator, published by CMS in the Physician Fee Schedule relative value file:

IndicatorPeriodTotal
000Procedure day only, no post-operative days1 day
01010 post-operative days11 days
090One pre-operative day, plus 90 post-operative days92 days
XXXThe global concept does not applyn/a
ZZZAdd-on code, follows the primary proceduren/a

Illustrative: indicator values and period definitions per the CMS global surgery methodology.

If you are guessing at a code's global period rather than looking it up, that is where the errors start.

What the package includes

  • Pre-operative visits after the decision to operate.
  • Intraoperative services that form a normal part of the procedure.
  • All post-operative visits related to recovery.
  • Post-surgical pain management by the surgeon.
  • Dressing changes, incision care, removal of sutures, staples and packing.
  • Complications that do not require a return to theatre.

What sits outside it

  • The visit at which the decision for major surgery was made, with modifier 57.
  • Unrelated evaluation during the period, with modifier 24 and a diagnosis that supports the unrelated nature.
  • A significant, separately identifiable visit on the same day as a minor procedure, with modifier 25.
  • Staged and related procedures, returns to theatre, and unrelated procedures, covered in the next section.
  • Diagnostic imaging. Only intra-operative films are bundled. Pre-reduction and follow-up films are separately reportable, with modifier 76 on a repeat post-reduction film.

The fracture care trap

Closed fracture treatment codes carry a 90-day global period even though no surgery takes place.

That has a consequence people get wrong constantly. Because fracture care is treated as major by virtue of its global period, the initial evaluation takes modifier 57, not 25. This is one of the most frequently asked questions in public coding forums, and the answer surprises people because the treatment does not feel like surgery.

The related decision: if you provide the restorative treatment but somebody else provides the follow-up, the fracture care code takes modifier 54 for surgical care only, and the follow-up physician needs to know the date.

Section 4 — free orthopedic coding tool

Global period and post-op modifier checker

Enter the original procedure's global period and the two dates, answer three questions about today's service, and it tells you whether it is billable and which modifier applies. Runs in your browser. There is nowhere to enter patient information and none is needed.

Select a global period, or choose "I don't know" to look it up.

Educational reference only. Not coding, billing or legal advice. Results follow Medicare and CPT rules as of the date shown. Commercial and workers' compensation payers may differ. Verify against the current fee schedule and your payer policy before billing.

This tool also lives at its own address: /tools/global-period-checker/.

Section 5

Do we use 58, 78 or 79?

Ask two questions in order. Is the second procedure related to the first? If not, it is 79, paid in full, and a new global period starts. If it is related, was it planned, staged, or more extensive than the original? Then it is 58, paid in full, with a new global period. If it is related and unplanned, a complication requiring a return to theatre, it is 78, paid at the intraoperative portion only, and no new global period begins.

The decision, in order

  1. 1

    Unrelated to the first procedure?

    79. Full payment, new global period.

  2. 2

    Related, and planned, staged, or more extensive?

    58. Full payment, new global period.

  3. 3

    Related, unplanned, and requiring a return to theatre?

    78. Intraoperative portion only, typically 70 to 80 percent, no new global period.

Why this is the most expensive modifier decision in orthopedics

Getting 58 and 78 the wrong way round costs you twice on every affected case.

Applying 78 where 58 was correct gives up 20 to 30 percent of the fee, and forfeits the new global period, which means the follow-up care you provide over the next ninety days is bundled into a payment that was already reduced.

Applying 58 where 78 was correct is the other direction, and it is an audit finding rather than a shortfall.

Neither error is visible on a remittance. Both are only found by looking.

The trap on 78

Modifier 78 requires a return to an operating theatre, procedure room or endoscopy suite. A related complication managed in the office is not 78, whatever it feels like clinically. It is either bundled into the global package or handled another way, and billing 78 for it will deny.

Section 6

Why do our modifier 22 claims never get paid?

Because every one of them goes to manual clinical review, and most submissions do not give the reviewer what they need. Modifier 22 pays when the documentation quantifies the additional work against a typical case. It does not pay because the surgeon found the operation difficult, however true that is.

What actually supports it

Two documents, not one:

  • A concise statement, separate from the operative note, contrasting this case against a typical case of the same procedure.
  • An operative report that quantifies the extra work. Numbers, not adjectives. Operative time stated against the usual range. Blood loss in millilitres against the usual, and what was done to control it. Extensive adhesions and the lysis performed. Trauma complicating the procedure and how.

What fails

  • General statements of difficulty.
  • "The case was complex."
  • "This took significantly longer."
  • A reviewer cannot act on those, so they do not.

Two things to know before you bother

Modifier 22 applies only to codes carrying a 0, 10 or 90-day global period. Appending it to a non-surgical code achieves nothing; the claim pays at the normal allowance.

And there is no reliable published figure for how often 22 succeeds. The claim that 22 claims are denied at roughly twice the rate of others circulates widely and traces to billing company content rather than to any independent dataset. We are not going to repeat it as a fact.

When not to bother

If the operative note does not already contain quantified detail, the answer is either to fix the dictation habit or to stop submitting 22. Appending the modifier to a note that does not support it generates review time, delays the rest of the payment, and does not produce the uplift.

That is a documentation decision made in theatre, not a billing decision made afterwards.

Section 7

How is workers' compensation different, and should you take it?

It is a separate billing world rather than a variation on group health. Fifty state systems plus federal programmes, each with its own fee schedule, authorisation process, forms and dispute path. The payer is an insurance carrier or administrator with an adjuster who approves care case by case. It frequently pays above Medicare, and it is frequently the worst-handled part of an orthopedic practice's revenue cycle.

Why it pays well and collects badly

The Workers' Compensation Research Institute's 2025 study of fee schedules across 44 states and the District of Columbia found rates ranging from marginally below Medicare in one state to double Medicare in another, with professional services accounting for around 41 percent of workers' compensation medical costs.

So the gross opportunity is real. Whether you realise it depends entirely on whether your practice can carry the authorisation discipline, the documentation, the forms and the slow accounts receivable.

What it demands that group health does not

  • Authorisation before elective treatment, controlled by the adjuster rather than the physician. Record the authorisation number and the approval for every service, because a dispute a year later turns on whether you can produce it.
  • Causation. Whether the condition is work related, stated explicitly.
  • Work status at every visit. Restrictions, capacity, return to work.
  • Impairment ratings under the applicable edition of the AMA guides, which varies by state.
  • State-specific forms, on state-specific deadlines.

The work most practices never bill

Report writing, disability examinations and testimony are billable and routinely go uncaptured.

Special reports have their own code. Work-related and disability examinations have their own codes, distinguished by whether the examining physician is the treating physician. Some states run separate medical-legal fee schedules with their own codes for evaluations, supplemental reports and deposition testimony, often with a minimum billing period.

If nobody in your practice knows which of these applies in your state, that work is being done for nothing.

Where the money actually leaks

  • Treatment delivered without adjuster authorisation.
  • Authorisation numbers not recorded.
  • The wrong fee schedule applied, in either direction.
  • Report and testimony time unbilled.
  • Claims stalling between carriers on coordination or liens.

Public dispute decisions show carriers denying evaluations delivered on the same day as surgery for missing modifiers, and denying codes not evidenced in the operative report. The same modifier discipline that governs group health applies here, against a payer with more procedural grounds to refuse.

Should you take it at all?

An honest answer rather than a reflexive yes.

Take it if you have staff who understand the authorisation and documentation requirements, or a biller who genuinely handles workers' compensation rather than treating it as group health with a different address.

Think harder if you do not. The premium over group health is real, and a practice without the discipline gives most of it back in denials, unbilled report work and receivables that age past anything you would tolerate elsewhere.

Section 8

Is it worth dispensing braces in the office?

Sometimes, and less often than the convenience argument suggests. Dispensing durable medical equipment requires supplier enrolment, accreditation from an approved organisation, and a surety bond of $50,000 per location, unless the physician dispensing exception applies. Add the modifier discipline and the audit exposure, and at low volume the compliance cost can exceed the margin.

What it takes to do it at all

  • Accreditation from a CMS-approved organisation.
  • A national provider identifier for each location.
  • Supplier enrolment.
  • The application fee.
  • A surety bond of $50,000 per identifier, subject to an exception for physicians furnishing equipment only to their own patients as part of their own service.
  • Revalidation every three years.

That exception is fact specific and worth confirming before relying on it.

The modifier that decides whether you get paid

The KX modifier attests that documentation on file meets the coverage criteria. Omitting it is the single most common mechanical denial on brace claims.

It is also not a substitute for the documentation itself. Appending KX where the file does not support it is precisely what audits look for.

Prior authorisation, which moves in both directions

Certain braces require prior authorisation nationally, and the list changes. Some codes dropped off the requirement in 2024. Others were added nationwide from 13 April 2026.

Check the current CMS and DME MAC list rather than working from what was true when you set the process up. A practice dispensing against a two-year-old understanding of the requirements will be denied on codes that changed underneath them.

When it is not worth it

If you dispense a handful of braces a month, the accreditation, the bond, the revalidation, the documentation discipline and the audit exposure are unlikely to be repaid by the margin.

In-office dispensing suits practices with the volume and the administrative discipline to run it cleanly. It is a service line, not a convenience, and it should be evaluated as one.

Section 9

What changed in 2025 and 2026

Three things worth knowing. CMS broadened modifier 54 across all 90-day global packages and created add-on code G0559 for post-operative follow-up by a practitioner who did not perform the surgery. Federal audits concluded that post-operative visits happen less often than global period valuations assume. And the 2026 fee schedule pairs a positive conversion factor with an efficiency adjustment that reduces most non-time-based codes, including surgery.

Global period policy

Modifier 54, for surgical care only, now applies across all 90-day global packages wherever a practitioner expects to furnish only the surgical portion. That includes informal and expected transfers of care, not only formally documented ones.

Alongside it, G0559 covers a post-operative follow-up visit furnished by a practitioner who did not perform the surgery and is not in the same group, once per 90-day global, where there was no formal transfer of care.

The audits, and why they matter to you

OIG report A-05-20-00021, published June 2025, examined whether the post-operative visits built into global surgery valuations are actually being furnished. It concluded they are not, at scale, and that the data CMS collects on those visits is often inaccurate.

The relevance is not that anyone is coming for your practice tomorrow. It is that the direction of travel is toward paying for post-operative care that is documented rather than assumed. Practices that record post-operative visits properly are better placed than those that do not.

The 2026 fee schedule

Two conversion factors for the first time, one for qualifying alternative payment model participants and one for everyone else, both higher than 2025.

Against that, an efficiency adjustment of 2.5 percent applied to the work values and intra-service time of nearly all non-time-based codes. Surgery is squarely in scope, so the headline increase does not reach orthopedic procedural work intact.

Facility practice expense values were also reduced, with physician payment for services performed in a facility dropping around 7 percent overall.

Section 11

Should you outsource or hire a certified coder?

If you have a coder who gets the global period modifiers right, handles workers' compensation as its own discipline, and works denials rather than adjusting them off, keep them. That combination exists and it is worth more than any vendor. The case for outsourcing strengthens as surgical volume, workers' compensation exposure and ancillary lines grow.

Three checks you can run this week

  1. 1Pull every claim from the last quarter carrying modifier 78. How many were actually staged or more extensive procedures that should have been 58?
  2. 2Pull your workers' compensation accounts receivable. How much of it is sitting on missing authorisation numbers rather than on genuine payer delay?
  3. 3Pull your denied brace claims. How many were missing KX?

Those three answers tell you more about your billing than any sales conversation, ours included.

In house is right when

  • Your coder applies the global period modifiers correctly and can explain why
  • Workers' compensation is handled by someone who knows the state rules
  • Denials are worked and appealed
  • Volume and case mix are stable

Outsourcing makes sense when

  • Any of the three checks returns a number you do not like
  • Workers' compensation receivables are ageing and nobody owns them
  • One person holds all the knowledge with no cover
  • You are adding surgeons or service lines faster than billing capacity

How to test any vendor, including us

  • Ask them to explain the difference between 58 and 78 and what happens to the global period in each case. Anyone who hesitates does not do orthopedics.
  • Ask which state workers' compensation fee schedules they work with.
  • Ask for denial reporting by surgeon, not in aggregate.
  • Ask what happens to a modifier 22 claim in their process.

We would rather you asked than took our word for it.

What we cannot do

We cannot make an adjuster authorise treatment, change a state fee schedule, or produce documentation for a modifier 22 claim that the operative note does not support. What we can do is get the modifier right the first time, capture the workers' compensation work that is currently unbilled, and make sure denials are worked rather than adjusted off.

Section 12

Get a free 48-hour AR audit

We look at your claim data and tell you what is not being worked, where the denials cluster, and what it is costing you. For an orthopedic practice that usually starts with the global period modifiers and the workers' compensation ageing. No obligation and no requirement to change anything. If your billing is clean, we will say so.

Surgeons
Workers' comp
Ancillaries
Your details

How many surgeons?

Section 13

Common questions

Fracture care: modifier 25 or 57?+

57, in most cases. Closed fracture treatment codes carry a 90-day global period, which makes them major procedures for modifier purposes even though no surgery takes place. The initial evaluation at which you decide to treat therefore takes 57. This catches experienced coders out because the treatment does not feel like surgery.

Can we bill chondroplasty with a meniscectomy on the same knee?+

No. Chondroplasty is included in the meniscectomy codes by description, and the edit pairs generally do not permit a modifier override. Where chondroplasty is performed in a different compartment, Medicare requires a specific code rather than the standard one, and it reimburses considerably less. Commercial payers may handle it differently.

How many units for an injection when we aspirate and inject the same joint?+

One. The code is reported once per joint regardless of how many aspirations or injections were performed, or how many bursae were treated. You also cannot report both the guided and unguided version for the same joint. Different joints take a distinct procedural modifier plus laterality. Bilateral major joints take modifier 50.

Do we bill the imaging globally or with modifier 26?+

Globally, with no modifier, if you own the equipment and interpret the film in your office. Modifier 26 is for interpreting a study performed on someone else's equipment, and appending it when you own the machine underpays you significantly. Modifier 26 also requires a separate signed written report; a line in the chart note is treated as bundled into the visit.

What ICD-10 detail do injury claims need?+

Laterality, and the correct seventh character for encounter type. Initial encounter means active treatment, which includes the first orthopedic visit after an emergency department presentation, rather than literally the first encounter anywhere. Routine follow-up during healing takes a different character. Coding software commonly drops the seventh character, which drives denials that look inexplicable.

When is an assistant at surgery payable?+

It depends on the indicator assigned to the procedure code, not on whether an assistant was present. Physician assistants, minimum assistants and non-physician assistants each take different modifiers and pay at different rates, with non-physician assistants paid a percentage of the physician assistant allowance. Check the indicator before assuming.

Do you handle workers' compensation?+

Yes, including authorisation tracking, state fee schedule application, and the report and testimony codes that commonly go unbilled. Worth telling us at the audit stage which states you operate in, because the rules differ enough that it changes what we look at.

What does it cost?+

A percentage of collections, quoted after the free 48-hour AR audit rather than before, because a rate given without seeing your claim data is a guess. No setup fee, no monthly platform fee, no minimum, month to month with 30 days notice. Full detail on the pricing page.