Orthopedic Surgery Billing Best Practices: For Joint Replacements and Fracture Care

Orthopedic surgery is one of the most technically demanding specialties in modern medicine. From total joint replacements to complex fracture repairs, these procedures are vital for restoring mobility, reducing pain, and improving patients’ quality of life. But behind every successful surgery is a challenge many practices struggle to master: accurate billing and coding.

With multiple coding layers, modifier dependencies, global period considerations, and evolving payer policies, orthopedic surgery billing best practices are essential—not just for compliance, but for sustainable revenue.

“Surgical precision shouldn't end in the OR — your coding and billing need the same level of accuracy to keep your practice thriving.”

— Orthopedic Revenue Cycle Specialist

Understanding the Intricacies of Orthopedic Surgery Billing

Orthopedic billing presents unique challenges that differentiate it from other specialties:

1. Complex, Multi-Component Procedures

A single orthopedic surgery often involves:

• Bone grafting

• Hardware placement (e.g., plates, screws, rods)

• Tendon or ligament repair
  Each of these may have distinct CPT codes—or be bundled—depending on how they’re performed and documented.

2. Modifier Dependencies

Orthopedic coding frequently uses modifiers to indicate:

• Laterality: -LT, -RT

• Bilateral procedures: -50

• Distinct procedural services: -59

• Assistant surgeons: -80, -82

Incorrect or missing modifiers are a top cause of orthopedic claim denials.

3. Global Surgical Periods

Many orthopedic procedures carry a 90-day global period. During this time, routine post-op visits and certain services are included in the original surgical fee. Misbilling within this window—especially without modifier -58, -78, or -79—can result in payer rejections.

4. Prior Authorization Requirements

Joint replacements, spinal surgeries, and high-cost implants often require advanced authorization. A missing pre-cert can result in total claim denial, regardless of clinical necessity.

5. Complex Cases (Workers’ Comp, Auto Injury)

These cases require:

• Additional documentation

• State-specific rules

• Extended timelines

• Clear differentiation between medical necessity and accident causality

Joint Replacement Billing: Keys to Accurate Coding and Maximum Reimbursement

Total joint replacements are among the most frequently performed—and scrutinized—orthopedic procedures.

Common Joint Replacement CPT Codes:

JointPrimary CPT CodeRevision CodesHip2713027134, 27137, 27138Knee2744727486, 27487Shoulder2347223473, 23474

Best Practices:

• Primary vs. Revision: Revisions are more complex and reimbursed at higher rates. Ensure operative reports clearly indicate whether it’s a first-time or revision procedure.

• Component Identification: For revisions, note exactly which parts (e.g., acetabular, femoral, tibial, patellar) were replaced—specific CPT codes exist for single-component revisions.

• Hardware Removal: Only billable separately if it’s performed through a different incision or at a different anatomical site.

• Anesthesia and Assistant Surgeons: Ensure proper use of modifiers -AA (anesthesiologist), -QX/-QK (CRNAs), and -80/-82 (assistants), with clear documentation of necessity.

• Medical Necessity: Documentation should include imaging reports, functional limitations, failed conservative treatments, and patient history.

Fracture Treatment Billing: Getting the Details Right

Fracture coding hinges on three key variables:

1. Anatomical site

2. Treatment method

3. Use of manipulation or fixation

Examples of CPT Code Scenarios:

• Closed Treatment without Manipulation
  Example: 25600 – Distal radius fracture, no manipulation

• Closed Treatment with Manipulation
  Example: 26755 – Distal phalanx, with manipulation

• Open Reduction with Internal Fixation (ORIF)
  Example: 27535 – Tibial plateau fracture, open treatment

• Percutaneous Fixation
  Example: 27265 – Post-arthroplasty dislocation, percutaneous reduction

Fracture Billing Tips:

• Casting and Splinting: Initial cast is often included in the procedure code. New or replacement casts may be separately billable.

• E/M Coding on Same Day: Use modifier -25 if the office visit led to a minor procedure. For major surgery (90-day global), use modifier -57.

• Multiple Fractures or Sites: If separate treatment is performed for different anatomical sites, ensure proper use of modifier -59 to indicate distinct procedures.

General Orthopedic Billing Best Practices

To support accurate coding and optimize reimbursement across all orthopedic procedures:

1. Comprehensive Documentation

Include:

• Operative notes with surgical approach, findings, and fixation technique

• Laterality and procedure details

• Medical necessity (e.g., X-ray/MRI findings, physical limitations)

• Specific devices and implants used

2. Prior Authorization and Coverage Verification

For elective surgeries, ensure:

• Procedure codes and diagnoses match the authorization

• Coverage details are verified for facility, assistant surgeon, and implants

• Medical necessity is pre-established

3. Modifier Mastery

Ensure staff are trained to apply:

• -LT/-RT: Always required for unilateral procedures

• -50: For same-day bilateral surgeries (if allowed by payer)

• -59: For non-overlapping, separately performed procedures

• -58/78/79: For services during the global period

4. Ongoing Coding Education

• Regularly update staff on CPT and ICD-10 changes

• Review Medicare NCCI edits quarterly

• Provide training for new surgical procedures or implants added to your service line

5. Claims Audit and Denial Management

• Perform internal audits at least quarterly

• Monitor denial trends and conduct root cause analysis

• Have a structured appeals process with supporting documentation templates

Partnering with Orthopedic Billing Experts

Orthopedic surgery billing requires deep procedural knowledge, an agile response to coding updates, and airtight documentation. For many practices, managing this in-house leads to lost revenue, compliance risk, and administrative burnout.

That’s why Medical Billing Wholesalers offers orthopedic-specific billing services designed to:

• Reduce denials related to modifier misuse, bundling errors, or global period violations

• Capture every eligible charge from complex surgeries

• Shorten payment cycles with clean claim submission

• Improve documentation with coding feedback to providers

• Navigate workers’ comp, personal injury, and payer-specific nuances with ease

Final Thoughts: Precision in Billing Matches Precision in Surgery

Orthopedic surgery changes lives—but only if the practice performing it can stay financially healthy. Adopting orthopedic surgery billing best practices ensures your team gets paid accurately, stays compliant, and focuses on what matters most: patient outcomes.

Don't let claim errors cut into your margins. Partner with a billing team that understands your specialty as deeply as you do. Let Medical Billing Wholesalers be your revenue partner in orthopedic care.