Orthopedic Billing and Coding Basics: Common Codes, Modifiers & Tips
Highlights
- Orthopedic billing requires accurate use of CPT, ICD-10, and modifiers due to complex procedures.
- Fracture care, surgeries, and follow-up visits must be coded differently based on treatment stage.
- Correct modifier usage is critical to avoid denials and underpayments.
- A structured orthopedic coding cheat sheet improves claim accuracy and faster reimbursements.
What Is Orthopedic Billing and Coding?
Orthopedic billing and coding is the process of translating orthopedic diagnoses, treatments, and procedures into standardized medical codes and submitting claims to insurance companies for reimbursement.
Orthopedic services include:
- Fracture care
- Joint replacement surgeries
- Arthroscopy
- Spine procedures
- Sports injury treatments
- Physical therapy referrals
Each service has specific coding rules that must be followed carefully.
Common Orthopedic Procedure Codes (CPT Examples)
CPT codes describe what procedure was performed.
Evaluation & Management (E/M)
- 99202–99205 (New patient visits)
- 99212–99215 (Established patient visits)
Fracture Care
- 25500 – Closed treatment of distal radius fracture
- 27230 – Closed treatment of femoral fracture
Joint Procedures
- 20610 – Joint injection (knee, shoulder)
- 29827 – Arthroscopic rotator cuff repair
- 27447 – Total knee replacement
Spine Procedures
- 63030 – Lumbar discectomy
- 22612 – Spinal fusion
Orthopedic Modifiers Cheat Sheet
Modifiers are extremely important in orthopedic billing.
| Modifier | Meaning | When to Use |
|---|---|---|
| -25 | Significant E/M service | Office visit + procedure on same day |
| -26 | Professional component | Interpretation only |
| -50 | Bilateral procedure | Same procedure on both sides |
| -51 | Multiple procedures | More than one procedure same session |
| -59 | Distinct procedural service | Separate procedures, different sites |
| -RT / -LT | Right / Left side | Laterality |
| -24 | Unrelated E/M during global period | Separate medical issue |
| -79 | Unrelated procedure during global period | New surgery |
Global Surgical Periods in Orthopedics
Orthopedic procedures often include global periods.
| Global Period | Meaning |
|---|---|
| 0 days | Minor procedure |
| 10 days | Minor surgery |
| 90 days | Major surgery |
During the global period:
- Routine follow-ups are not separately billable
- Use correct modifiers if billing unrelated services
Fracture Care Coding Rules (Important)
Fracture coding depends on:
- Initial encounter
- Subsequent encounter
- Healing stage
ICD-10 Fracture Extensions
- A – Initial encounter
- D – Subsequent encounter (routine healing)
- G – Delayed healing
- K – Nonunion
- P – Malunion
Example:
S52.501A → Initial encounter for fracture
S52.501D → Follow-up visit
Common Orthopedic Billing Errors
Avoid these common mistakes:
- Using incorrect modifiers
- Billing E/M incorrectly with procedures
- Ignoring global period rules
- Missing laterality (RT/LT)
- Mismatch between ICD and CPT codes
- Incomplete documentation
These errors often result in denied or underpaid claims.
Best Practices for Orthopedic Billing and Coding
- Always review operative reports carefully
- Match diagnosis with procedure codes
- Use modifiers correctly and sparingly
- Track global surgical periods
- Verify insurance authorization
- Maintain proper documentation
- Audit claims regularly
Why Orthopedic Practices Outsource Billing
Many orthopedic practices outsource billing because:
- Orthopedic coding is highly specialized
- Reduces claim denials
- Improves cash flow
- Saves administrative time
- Ensures compliance
Expert billing teams stay updated with coding changes and payer rules.
FAQs
1. Why is orthopedic billing more complex than other specialties?
Orthopedic billing involves surgeries, fracture care, global periods, modifiers, and multiple follow-ups. Each step has strict coding rules, making it more complex.
2. Can an E/M visit be billed with an orthopedic procedure?
Yes, but only when the visit is significant and separately identifiable. Modifier -25 must be used with proper documentation.
3. What is the global period in orthopedic surgery?
It is a fixed time (usually 90 days) after surgery during which routine follow-up care is included in the surgical payment.
4. How are fracture follow-up visits coded?
Follow-up visits use the same fracture code with a different ICD-10 extension such as D (routine healing).
5. What modifiers are most commonly used in orthopedics?
Common modifiers include -25, -26, -50, -51, -59, RT, LT, and -79.