Orthopedic Billing & RCM

Orthopedic billing and revenue cycle, 50-state coverage.

Orthopedic billing and revenue cycle services from ASP-RCM Solutions. 20,153 NPPES orthopedic billing providers across all 50 states + DC. HIPAA + SOC 2 Type II compliant. Senior partners on every account.

Free orthopedic billing audit → See 50-state coverage

What good orthopedic billing execution looks like.

The operating discipline we install on every orthopedic billing engagement.

Bundling edit management for surgical orthopedic claimsOrthopedic surgery claims carry extensive bundling logic (NCCI edits, modifier 59, X-modifiers). Coders working orthopedic in need depth in bundling rules to capture every legitimate code without triggering audits.
Modifier 25 / 59 discipline for office visits + proceduresOrthopedic practices routinely perform injections, fracture care, and casting during office visits. Modifier 25 separating E/M from procedure and modifier 59 or X-modifiers separating distinct procedures must be defensible.
Global period management for surgical episodes90-day global periods on most major orthopedic surgeries mean post-op visits during the global are not separately billable. Orthopedic billing teams need disciplined global period tracking.
Prior authorization for orthopedic MRI and DMECommercial payers and state Medicaid programs require PA for most orthopedic MRI imaging, joint injections, and durable medical equipment. AI-supported PA automation is high-ROI for orthopedic practices.
Workers' comp billing workflowWorkers' compensation cases require distinct billing workflow: state-specific WC fee schedules, employer or carrier authorization, attorney correspondence. Separate from commercial billing operations.
Joint replacement bundled payment coordinationTotal knee and hip replacement bundled payment programs (BPCI, CJR) coordinate hospital + surgeon + post-acute payment. Orthopedic groups participating in bundles need cross-provider billing alignment.

Surgical episode revenue map

One orthopedic episode, and the four places it leaks.

An orthopedic case is not one claim. It is an authorization, a surgical package, a ninety day global window, an implant invoice, a braced patient walking out of the office, and a course of physical therapy. Each handoff is a place revenue disappears, and none of them are visible from the clearinghouse.

Diagram describes the ASP-RCM operating model for an orthopedic surgical episode. It is a workflow map, not a claim of denial frequency. Your own leak profile is measured during the free 30-day audit against your last 90 days of claim data.

The rules that govern the episode

Six orthopedic billing numbers you should know cold.

Each figure below carries its source. We do not publish benchmarks we cannot point at.

090

The major surgery global indicator

Most major orthopedic procedures carry a 090 global indicator: one preoperative day, the day of surgery, and 90 days after it. Minor procedures carry 010 or 000. The indicator, not intuition, decides what is separately billable.

CMS Medicare Physician Fee Schedule Relative Value File, GLOB DAYS field; CMS Global Surgery Booklet

28%

Of assumed 90-day post-op visits actually furnished

Across 2023 global surgical volumes, only 28 percent of the postoperative visits assumed in the Physician Time File for 90-day global procedures were actually provided as part of the global package. The global package is priced on assumptions your practice may not match.

CMS, CY 2026 Medicare Physician Fee Schedule final rule, 90 FR 49266

Same figure for 10-day globals

For 10-day global procedures the same analysis found only 2 percent of assumed postoperative visits were furnished inside the package. That gap is the reason CMS keeps revisiting how global surgical services are valued.

CMS, CY 2026 Medicare Physician Fee Schedule final rule, 90 FR 49266

99024

The no-pay post-op reporting code

CMS built a claims-based reporting system requiring practitioners in nine states, and in practices of 10 or more NPIs, to report postoperative visits falling within global periods using no-pay HCPCS code 99024. It pays nothing and it is still mandatory where it applies.

CMS, CY 2026 Medicare Physician Fee Schedule final rule, 90 FR 49266

424.57

The rule behind office-dispensed DME

Braces, boots, walkers and bone stimulators handed to a patient in your office are DMEPOS. Supplying them requires a separate supplier enrollment meeting the supplier standards at 42 CFR 424.57, including accreditation and a surety bond. Clinical need alone does not make the claim payable.

42 CFR 424.57, DMEPOS supplier standards and enrollment

20,153

Orthopedic orgs in NPPES

Orthopedic billing organizations registered across all 50 states and DC. ASP-RCM publishes a field guide for every one of them.

NPPES registry, ASP-RCM specialty universe build

Global period modifier decision table

Five modifiers decide whether post-op work gets paid.

Once a 90-day global period opens, every subsequent encounter has to answer one question: is this inside the package, or outside it. Five modifiers carry that answer, and two of them behave very differently on payment even though practices use them interchangeably.

Modifier	What it asserts	The orthopedic situation it fits	Payment and global period effect
24	Unrelated E/M during a postoperative periodEvaluation and management only	A knee replacement patient returns inside the 90 days for a shoulder complaint that has nothing to do with the knee.	Separately payable when the diagnosis and the note carry the unrelated problem on their own. Does not disturb the running global period.
25	Significant, separately identifiable E/M on the day of a procedureSame day, same physician	A new patient is evaluated and injected at the same visit, or evaluated and casted at the same visit.	Separately payable when the evaluation stands on its own in the record, independent of the work already bundled into the procedure.
58	Staged or related procedure during the postoperative periodPlanned from the outset	A planned second stage, or planned hardware removal that was contemplated when the index procedure was performed.	Paid at the full fee schedule amount, and a new postoperative period begins on the staged procedure.
78	Unplanned return to the operating or procedure roomRelated to the index procedure	Evacuation of a postoperative hematoma, a washout for infection, or revision after fixation failure inside the global window.	Paid at the intraoperative portion of the fee only, and it does not start a new postoperative period. This is where practices overstate what they will collect.
79	Unrelated procedure during the postoperative periodDifferent problem entirely	Surgery on the contralateral knee while the first knee is still inside its 90 day global period.	Paid at the full fee schedule amount, and a new postoperative period begins. Confusing this with 78 is the single most expensive modifier error in orthopedics.

Modifier definitions and their payment treatment follow the CMS global surgery policy in the Medicare Claims Processing Manual, Chapter 12, and the CMS Global Surgery Booklet. Commercial and workers compensation payers publish their own edits on top of that policy, which is why we hold the rule set per payer rather than nationally.

Revenue leakage taxonomy

The five places orthopedic revenue actually leaks.

Orthopedic leakage is rarely a rejected claim. It is a cost that never became a charge, a visit that was assumed to be free, or a case routed into the wrong billing workflow entirely. This is the taxonomy we work against on every orthopedic engagement.

Leakage driver	How the dollars go missing	The control we install	Where it bites
Global period boundariesInside or outside the package	Post-op encounters get billed without modifier 24 or 25 and deny, or the opposite happens and genuinely unrelated care is written off as being in the global because nobody wanted the argument.	Global day indicator loaded per CPT and enforced at charge entry, a documented inside or outside decision on every post-op encounter, and 99024 reporting wherever CMS requires it.	Days 1 to 90
Implant and hardware captureCost that never becomes a charge	The implant, plate, screw set or graft is consumed in the case and the cost stops at the vendor invoice in materials management. It never reaches the claim, the carve-out or the workers compensation invoice line that would have paid it.	Implant log reconciled to the operative note case by case, then matched to the payer contract terms so invoice-priced and carve-out items are billed the way that specific contract pays them.	Day of surgery
Office-dispensed DMEBraces, boots, stimulators	Equipment is handed to the patient at the visit without the DMEPOS supplier enrollment behind it, without the order documented before dispense, or without the correct L-code and modifier combination. The care happened and the claim has nowhere to go.	DMEPOS enrollment verified and maintained, an order-before-dispense gate at the point of care, and L-code plus modifier validation before the charge is released.	At dispense
Fracture care versus E/MTwo legitimate billing paths	Fracture care codes carry their own global period, so the practice either bills the fracture care code and the visit together without support for both, or defaults to the visit alone and leaves the fracture care code unbilled for the entire episode.	A documented decision rule per encounter covering which path applies, what the note has to show for each, and how follow-up inside the resulting global period is handled.	First encounter
Workers compensation and auto or PIPWrong workflow entirely	These claims land in the commercial queue, get priced off the wrong fee schedule, and go out without the carrier authorization number, the state-required form or the attorney correspondence trail. They then age quietly because nobody owns them.	Separate workers compensation and auto or PIP queues with state fee schedule tables, carrier authorization tracked as a first-class object, and correspondence handled as part of the claim rather than as filing.	At intake

The table describes ASP-RCM's operating taxonomy and the controls we install. It does not assert leakage frequencies. Your own mix is measured per practice during the free 30-day audit against your last 90 days of claim data.

Top orthopedic billing markets by NPPES org count.

State-level RCM guides for the largest orthopedic billing markets in the U.S.

California2,269 orgs → Florida1,760 orgs → Texas1,624 orgs → New York1,361 orgs → New Jersey832 orgs → Pennsylvania749 orgs → Michigan723 orgs → North Carolina674 orgs →

View all 50 state guides →

Orthopedic billing FAQ

Questions orthopedic practice administrators actually ask.

What is the global surgical period in orthopedic billing?

It is the window in which routine care connected to a procedure is already paid for inside the procedure's fee. Medicare assigns every surgical code a global indicator: 090 for major surgery, which covers one preoperative day, the day of surgery and the 90 days after it, and 010 or 000 for minor procedures. Most major orthopedic surgery carries a 090 indicator. The indicator lives in the Physician Fee Schedule Relative Value File, and it decides what is separately billable during that window rather than clinical judgment about how much extra work the visit felt like.

When do I use modifier 78 instead of modifier 79?

Modifier 78 is for an unplanned return to the operating or procedure room for something related to the original surgery, such as a washout, a hematoma evacuation or a revision after fixation failure. It pays only the intraoperative portion of the fee and it does not start a new postoperative period. Modifier 79 is for a procedure that is genuinely unrelated to the first one, such as operating on the contralateral knee while the first knee is still inside its 90 days. It pays the full fee schedule amount and it starts a new postoperative period. Practices that use them interchangeably systematically misstate what the case will collect.

Can an orthopedic practice bill an office visit on the same day as an injection or casting?

Yes, when the evaluation is significant and separately identifiable from the procedure, and it is reported with modifier 25. The test is what the record shows. Every procedure already includes a small amount of inherent evaluation work, so the note has to establish that a distinct evaluation happened beyond that inherent work, with its own history, examination and decision making. A new patient evaluated for a knee problem and then injected at the same visit usually meets it. A scheduled repeat injection on an established plan usually does not.

What does an orthopedic practice need in order to dispense DME in the office?

More than the equipment. Braces, boots, walkers and bone stimulators handed to a patient are durable medical equipment, prosthetics, orthotics and supplies, and supplying them requires a separate DMEPOS supplier enrollment that meets the supplier standards at 42 CFR 424.57, including accreditation and a surety bond. On top of enrollment the claim needs the order documented before the item is dispensed, the correct HCPCS L-code, and the modifier set the payer expects. Practices routinely dispense first and discover the enrollment or documentation gap at denial, by which point the item is already on the patient.

Why does workers compensation billing need a separate workflow from commercial billing?

Because almost nothing carries over. Workers compensation is regulated state by state, so the fee schedule, the required forms, the filing deadlines and the dispute process all change with the jurisdiction rather than with the payer. The claim usually depends on a carrier authorization tied to a specific claim number and body part, and the correspondence trail with adjusters and attorneys is part of getting paid rather than administrative overhead. Auto and personal injury protection claims behave similarly and add their own coordination rules. Run through a commercial queue, these cases get priced off the wrong schedule and then age quietly because no one owns them.

Free 30-day audit for orthopedic billing providers.

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Orthopedic billing by state.

Dedicated Orthopedic billing and credentialing field guides for 51 states. Each state guide opens into its city-level guides with local payer, Medicaid, and credentialing detail.