Orthopedics RCM & Billing Services

Common Review Areas

Orthopedic billing can involve procedure-specific authorization, modifier accuracy and rules that affect surgical and postoperative services.

• Procedure authorization
• Global surgery package rules
• Modifier accuracy
• Medical necessity
• Coordination between surgical and postoperative billing

How BlueBird Medserv Helps

We examine authorization and claim workflows, identify global-period and modifier-related issues, and review denials and payment variances affecting reimbursement.

Findings become a prioritized list of corrective actions, so the practice can address the process behind repeat delays and not only the individual claim. Examples on this page are illustrative; payer requirements, contracts and outcomes vary, and no financial outcome is guaranteed.

Global Surgery Periods: What Is and Is Not Billable

Many surgical procedures carry a global period of 0, 10 or 90 days. Care that is part of the package, such as the usual postoperative visits, is generally not paid separately, and for major surgery the visit the day before or the day of surgery is typically included as well. Payers publish or follow their own global-period assignments, and Medicare's are the common reference.

Problems arise when a visit is billed during the global period without the right modifier, or when unrelated care is bundled into the package by mistake.

• Know the global period assigned to each procedure and payer
• Track the surgery date and global end date so related visits are not billed in error
• Use a modifier only when documentation supports it
• Review denials with global-period reason codes by procedure and payer

Modifiers That Drive Orthopedic Payment

Prior Authorization, Imaging and Medical Necessity

Planned procedures such as joint replacement, arthroscopy and spine surgery commonly require authorization, and advanced imaging such as MRI often does too. Payers frequently look for documented conservative treatment before surgery, such as therapy or injections, along with imaging findings and functional limitation.

Authorization should be matched to the CPT code, the side and the facility. A change in the planned procedure on the day of surgery is a common reason an approved case is still denied.

Fractures, Casting, Injections and DME

Fracture care codes generally include the initial casting or splinting and the related follow-up for the global period, while cast and splint supplies may be reported separately under some payer rules. Joint injections may be reported with or without ultrasound guidance, and some payers treat guidance as included. Viscosupplementation drugs commonly require step-therapy or authorization.

Braces and other durable medical equipment add their own requirements: coding with HCPCS L-codes, supplier enrollment and, for some payers, specific documentation before dispensing.

Workers' Compensation and Accident Claims

Orthopedic practices see a high share of injury-related care. Workers' compensation, auto and other liability claims follow different submission, authorization and fee-schedule rules from group health, and a claim billed to the wrong payer first can delay payment. Correct payer order and accident details at registration make later follow-up much easier.

Codes, modifiers and payer rules change, and payers differ. Treat the examples below as orientation and verify against the current CPT/HCPCS code set and each payer's policy.

Where to Start

Begin with a review of your recent denials, payment variances and outstanding claims for orthopedics. See also our RCM Audit & Revenue Leakage Assessment, Denial Management and Insurance Eligibility & Verification services.