Orthopedic Billing and Coding Cheat Sheet

 Erika Regulsky RCM
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Reach a High Level of Orthopedic Revenue Cycle with Cheat Sheet for Orthopedic billing and coding

Optimizing the revenue cycle is vital for every medical practice, including orthopedics. The efficient handling of orthopedic medical billing operations ensures timely payments and reduces delays, resulting in improved cash flow. In pursuit of these objectives, practitioners need to take into account various factors beyond orthopedic billing and coding guidelines while billing for orthopedic medical services. Accurate billing practices and adherence to orthopedics coding guidelines reduce the likelihood of claims being denied, ultimately contributing to a smoother operation and financial stability for orthopedic practices. In this article, This orthopedic billing and coding cheat sheet will explore key aspects of orthopedic medical billing and coding, offering valuable advice to better manage income-derived resources.

Orthopedic Medical Billing

A well-managed revenue cycle begins with accurate orthopedic medical billing. Claims are less likely to be denied when information is analyzed accurately, and the appropriate codes and modifiers are applied. This not only assists the practice in generating a continuous stream of revenue but also helps maintain a smooth operation. The transition to ICD-10 has brought significant changes to orthopedic medical coding practices. With 264 new codes, the deletion of 143 codes, and modifications to 134 codes, orthopedic medical billing is undergoing a significant transformation. Additionally, the introduction of new rules for modifier 59 and the addition of relevant modifiers XE, XP, XU, and XS further impact the orthopedic medical coding and billing landscape for orthopedics.

Benefit and Coverage Verification

Among the essential aspects of orthopedic medical billing is ensuring and verifying that all insurance-related aspects have been addressed. This includes reviewing the patient’s insurance coverage and determining whether their insurance companies would cover the planned services. Initiating insurance coverage verification at the outset minimizes the likelihood of billing errors and subsequent denials for orthopedic claims.

Patient Information Confirmation

An important orthopedic billing services guideline is verifying the accuracy of all patient information, including spelling, address, contact information, demographic details, and other specifics. Even a minor error, such as an overlooked misspelled word, can lead to claim denials. Therefore, it is essential to thoroughly examine every detail before processing the claim.

Timely and Specific Coding

Timely and specific coding is critical for orthopedic medical billing. Ensuring your practice possesses comprehensive information on codes and covered diagnoses is crucial to authenticate the coding in your claims effectively. Moreover, you must ensure that the codes you use correspond with the actual diagnosis. To achieve this, it is essential to provide your billing staff with all the necessary information and tools to record claim codes promptly.

Orthopedic Revenue Cycle

Orthopedic Billing Codes

Current Procedural Terminology (CPT) codes form the backbone of orthopedic medical billing. These codes describe medical, surgical, and diagnostic services and aim to provide physicians with uniform information regarding medical services and procedures. Here are some essential CPT codes for orthopedic medical billing:

E/M or Evaluation and Management: 99201 – 99499
Anesthesia: 00100 – 01999; 99100 – 99140
Radiology: 70010 – 79999
Medicine: 90281 – 99199; 99500 – 99607
Pathology and Laboratory: 80047 – 89398
Surgery: 10021 – 69990
Hand Surgery (Repair of Nail Bed): 11760
Hand Surgery (Carpectomy; all bones of the proximal row): 25215
Hand Surgery (Neuroplasty/carpal tunnel release): 64721
Endoscopic Carpal Tunnel Release: 29848


Modifiers play a crucial role in orthopedic medical billing and coding. These are two-character codes that indicate how the treatment or services code should be utilized on the claim. Skillful utilization of modifiers enhances the precision and detail of a medical transaction record significantly. However, improper use of modifiers can result in claim denials. Here are some common modifiers used in orthopedic billing:

Modifier 59

Employed to distinguish procedures or services that are typically not reported together but are suitable under specific circumstances.

Level I Modifiers (CPT Modifiers)

Used to add to or modify care descriptions to provide extra information about an operation or service received.

Level II HCPCS Modifiers

Consist of two numbers (Alpha/Numeric characters) ranging from AA to VP, and they are updated annually by CMS (Centers for Medicare & Medicaid Services).
Applying modifiers correctly is crucial for the steady influx of cash flow. They indicate changes made to the main procedure code due to specific factors, impacting reimbursement.

Bundling and Unbundling

Understanding bundling and unbundling rules is essential for orthopedic medical billing. A bundling package determines whether surgical CPT codes can be reimbursed individually or collectively. For instance, a CPT code describing both a medial and lateral meniscectomy may be invoiced as a single procedure or bundled together, disallowing additional charges.

On the other hand, unbundling occurs when multiple CPT codes are billed for the component parts of a procedure when there is a single code available that includes the complete procedure. Unbundling errors are a frequent cause of claims denials and negative audit findings, while unnecessary bundling can harm reimbursement.

Global Period

Understanding global periods is crucial in orthopedic medical billing. A global period includes the preoperative and postoperative periods, during which all follow-up services are considered part of the global fee and cannot be billed separately. Code 99024 is an example of a 90-day post-operative period code.

Complexities in Orthopedic Medical Billing

Orthopedic medical billing comes with a unique set of complexities that practitioners must address to ensure smooth revenue cycle management. Accuracy is of utmost importance, and this begins with complete documentation before, during, and after patient visits. A denied claim could result from errors such as submitting insufficient patient information or failing to verify the patient’s eligibility beforehand. In addition to authorization verification, knowing the insurer’s preferences and deadlines can make it easier to get paid.

Compared to other specialties, orthopedic medical billing requires a deeper understanding of the services rendered and the complexities involved. A high number of denials could force your orthopedic clinic to lose money, provide substandard patient care, or even close down. It is crucial for practitioners to invest in skilled billing and coding staff who can effectively navigate the complexities of orthopedic medical billing.

Outsourcing Orthopedic Billing and Coding

While hiring an in-house billing team and providing them with proper training may help you avoid expenses and penalties, the orthopedic billing process is too complex for an in-house billing team to handle alone. Outsourcing your billing and coding needs to a specialized expert, such as BillingParadise, is one approach to alleviate stress on your staff and maximize the amount of money you are paid for your services.

BillingParadise is well-versed in orthopedic medical billing and coding, offering comprehensive solutions tailored to the specific needs of orthopedic practices. Their team of highly skilled coders and billers can handle the complexities of orthopedic medical billing, ensuring optimal reimbursement for the services rendered. By outsourcing billing and coding to BillingParadise, physicians can focus on delivering exceptional patient care while maintaining a steady influx of cash flow.


In conclusion, efficient revenue cycle management is critical for the success of any orthopedic practice. Proper orthopedic medical billing and coding practices are the pillars of a smooth and thriving revenue cycle. By adhering to orthopedic billing guidelines, understanding and implementing CPT codes, and using modifiers accurately, practitioners can streamline their billing processes and avoid claim denials.

Moreover, outsourcing billing and coding needs to specialized experts like BillingParadise can alleviate the burden on your staff and ensure maximum reimbursement for the services rendered. Orthopedic practices that invest in skilled orthopedic billing companies will not only optimize their revenue cycle but also provide exceptional patient care, ensuring long-term success and prosperity. Book a free demo with BillingParadise to see how they can assist your practice in achieving efficient revenue cycle management through streamlined orthopedic medical billing services.

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I’m a multi-certified revenue cycle management professional and compliance officer with 20+ years of experience. I contribute articles to leading healthcare publications and journals. I am currently working as Senior Transition Manager, in BillingParadise headquartered at Diamond Bar, California. BillingParadise offers Medical Billing Services that intersect perfectly with the EMR/Practice management system you use.BillingParadise has offices in New Jersey, New York, Florida, Georgia, Minnesota, and Texas.

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