Orthopedic & Rheumatology Billing, Credentialing

Surgical Billing Expertise

Surgical billing expertise stands as the foundation of orthopedic revenue cycle management. We correctly code procedures from simple arthroscopies to total joint replacements. Global surgical packages get managed properly, with appropriate billing for the surgery, related services during the global period, and unrelated services when medically necessary. We track global periods for each procedure, ensuring follow-up visits are billed correctly and complications requiring return to the operating room get coded with proper modifiers. The global period includes the surgery itself, typical post-operative visits, and management of normal recovery. What many practices miss is knowing when services fall outside the global package. A patient who returns with an unrelated injury during the global period deserves separate billing with Modifier 24. A complication requiring return to the OR gets billed with Modifier 78. We know these nuances and apply them correctly.

Injection and Aspiration Coding

Injection and aspiration coding requires precision that affects daily revenue in both specialties. Joint injections, bursa aspirations, trigger point injections, and therapeutic injections each have specific CPT codes based on the anatomic site. We apply the correct codes whether you’re injecting a major joint like the knee or a small joint in the hand. Modifiers matter enormously here. Bilateral knee injections during the same visit need Modifier 50. Multiple injections in different joints during one session need Modifier 59 or the more specific X modifiers. Imaging guidance adds another layer of coding requirements. When you use fluoroscopy or ultrasound to guide an injection, that guidance gets coded separately but only when properly documented. The documentation must show you personally performed the guidance, interpreted the images in real-time, and that the guidance was medically necessary for accurate needle placement.

Biologic Medication Management

Biologic medication management creates unique billing challenges in rheumatology practices. Drugs like infliximab (Remicade), adalimumab (Humira), rituximab (Rituxan), and tocilizumab (Actemra) cost thousands of dollars per dose. The buy-and-bill model means practices purchase these medications upfront and seek reimbursement after administration. Getting this billing wrong means substantial financial losses. We handle the entire biologic billing process. The drug administration gets coded separately from the medication itself using administration codes that specify whether the infusion was the first hour, subsequent hours, or a concurrent infusion. The medication gets billed using the appropriate J-code with units calculated based on the exact dose administered. NDC codes must match the specific formulation. Lot numbers need tracking for recall purposes. Waste documentation justifies billing for the full vial even when only a portion gets used. Prior authorization for biologics requires demonstrating medical necessity. Payers want to see that conventional DMARDs (disease-modifying antirheumatic drugs) were tried first and failed. Documentation must show disease severity justifies the expensive biologic therapy. We manage these prior authorization requirements, gathering clinical documentation that supports approval.

Fracture Care Billing

Fracture care billing trips up many orthopedic practices because global periods work differently than surgical global periods. When you provide initial fracture treatment, you’re billing for the global fracture care that includes most follow-up visits during the healing period. The global period varies by fracture type and treatment approach. A simple closed treatment might have a 90-day global period, while complex fractures requiring surgery have their own surgical global periods. Services included in fracture care global packages include the initial encounter, all routine follow-up visits for cast changes and healing checks, and removal of casts or splints applied during the initial treatment. Services NOT included are X-rays beyond the initial treatment, physical therapy after healing begins, treatment of complications, and care of new injuries unrelated to the fracture.

We track global periods for every fracture patient, ensuring your billing system knows which visits to bill and which are included in the global package. When services fall outside the global period, we code them separately with appropriate documentation showing medical necessity.

Modifier Application

Modifier application makes or breaks orthopedic and rheumatology billing. These specialties use modifiers more extensively than almost any other field.

Common modifiers we manage daily include:

• Modifier 25 for separately identifiable E/M services on the same day as a procedure
• Modifier 50 for bilateral procedures performed during the same session
• Modifier 51 for multiple procedures (though many payers no longer require this)
• Modifier 59 or X modifiers for distinct procedural services
• Modifier 76 for repeat procedures by the same physician
• Modifier 77 for repeat procedures by another physician
• Modifier 78 for return to the operating room for complications
• Modifier 79 for unrelated procedures during the global period
• LT and RT modifiers for left and right side designation

Modifier 25 gets particular scrutiny in musculoskeletal practices. When you perform an injection during an office visit, you can bill both the E/M service and the injection if the E/M was significant and separately identifiable. The documentation must show the E/M addressed issues beyond the typical pre-procedure assessment. Simply examining the joint before injecting it doesn’t support Modifier 25. Evaluating the patient’s overall disease activity, adjusting other medications, discussing treatment options, and addressing other health concerns does support separate billing.

Prior Authorization Management

Prior authorization management consumes enormous staff time in orthopedic and rheumatology practices. MRI and CT scans almost always require prior authorization. Biologic medications need authorization demonstrating failed conventional therapies. Surgical procedures require pre-certification with clinical documentation showing conservative treatments were attempted. We handle prior authorizations proactively, submitting requests as soon as services are scheduled rather than waiting until the last minute. This prevents appointment cancellations when authorizations aren’t ready. When authorizations get denied, we appeal immediately with additional clinical information, peer-to-peer review requests, and documentation showing medical necessity.

DME and Supply Billing

DME and supply billing adds revenue for orthopedic practices that dispense durable medical equipment and orthopedic supplies. Walking boots, knee braces, shoulder immobilizers, crutches, and other DME items provided to patients need proper coding and documentation. Some items are billed as purchases, others as capped rentals. Medicare has specific rules about DME that differ from commercial payer requirements. We code DME correctly based on the HCPCS codes that describe each item. Documentation must show medical necessity for the DME and that the patient received instruction on proper use. For capped rental items, we track the rental period and convert to purchase when appropriate. Compliance documentation gets maintained for audits.

Denial Management and Appeals

Denial management and appeals recover revenue that would otherwise be lost. Common denials in these specialties include bundling edits that incorrectly combine separately billable procedures, medical necessity denials for biologics or imaging, modifier errors where payers reject Modifier 25 or bundling modifiers, global period confusion where payers bundle services that should be separate, and authorization issues where services were performed without proper pre-authorization. We appeal every inappropriate denial with detailed clinical documentation, coding rationale based on CPT and payer guidelines, references to medical literature supporting treatment necessity, and peer comparison data when appropriate. Persistence pays off because many initial denials get overturned on appeal when supported by proper documentation.

Credentialing Benefits for Musculoskeletal Practices

• Subspecialty certifications are documented and highlighted appropriately for payers seeking specialists
• Hospital privileges are coordinated with insurance credentialing to prevent gaps
• Surgical center privileges are maintained alongside hospital credentials
• Multi-state licensing for practices serving border areas gets tracked continuously
• Fellowship training and specialized technique certifications are documented when relevant
  

Key Contracting Considerations for Orthopedic and Rheumatology Practices

• Surgical reimbursement must cover facility costs for ambulatory surgical centers, implant and supply costs for procedures requiring hardware or biologics, and surgeon professional fees that reflect the complexity and time involved. Some payers try to bundle facility and professional fees in ways that underpay one or both components. We negotiate contracts that recognize these as distinct services deserving appropriate separate payment.
• Biologic medication reimbursement requires careful contract language. The medication cost (billed with J-codes) should reimburse at a percentage above your acquisition cost, typically ASP (Average Sales Price) plus 4-6%. The administration fee (billed with administration codes) should compensate for nursing time, facility overhead, and supplies used during infusion. Some payers bundle administration into medication payment or pay administration fees too low to cover costs. We negotiate contracts that properly reimburse both components.
• Global period definitions need clarity in contracts. What specific services are included in surgical global periods? What constitutes a complication that justifies separate billing? When can E/M services be billed during the global period? Vague contract language leads to payment disputes. We negotiate specific definitions that align with CPT guidelines and protect your revenue.
• Fracture care global periods vary by payer. Some follow Medicare guidelines, others have proprietary global period definitions. Contracts should clearly state which services are included in fracture care codes and which can be billed separately. Physical therapy, advanced imaging, and treatment of new injuries should be billable separately, but some payers try to bundle these services.
• Prior authorization thresholds and processes significantly impact practice efficiency. Contracts with burdensome prior authorization requirements for routine services create administrative costs that reduce profitability. We negotiate to raise dollar thresholds that trigger authorization requirements, streamline authorization processes for routine procedures, or ensure reimbursement rates compensate for the administrative burden these requirements create.
• Implant and supply reimbursement in orthopedic contracts deserves special attention. Joint replacement surgeries, spine procedures, and some fracture repairs require expensive implants. Contracts should specify how implants are reimbursed. Are they included in the surgical fee or billed separately? If separate, what percentage of your acquisition cost gets reimbursed? Underpayment for implants means losing money on procedures even when surgical fees seem reasonable.