Orthopedic billing services exist because orthopedic revenue does not behave like the rest of medicine. A single episode of care can include a decision-for-surgery visit, a procedure with a 90-day global period, a cast, a brace dispensed from the closet down the hall, and an X-ray taken in your own office — each with its own rules and its own way of being denied. Getting paid depends less on submitting claims quickly than on knowing which services are already bundled and which are separately reportable. If you are starting from the fundamentals, our orthopedic billing guide for practices covers the same ground at a slower pace.
What makes orthopedic billing different from general medical billing?
Three structural features set orthopedics apart.
- Most of what you do carries a global period. Billing a visit inside that window without the right modifier produces a denial; failing to bill a legitimately separate service produces silent revenue loss that never appears on a denial report.
- You provide services that are not physician services. Casting supplies and braces are supply and DME claims, governed by different rules, enrollment requirements, and documentation standards than the procedure that made them necessary.
- You often own the imaging. The question becomes which component you are entitled to bill, and whether a written interpretation exists to support it.
A generalist biller can process an orthopedic claim. Whether they know that a cast reapplication during a global period is separately reportable while the initial cast is not is a different question — and one worth asking when you evaluate a medical billing company.
How do global surgical periods work in orthopedics?
Medicare’s global surgery policy assigns every procedure a postoperative period. The CMS Global Surgery Booklet defines the categories:
| Global period | What it covers |
|---|---|
| 0-day (minor procedures and endoscopies) | No preoperative period and no postoperative days. The visit on the day of the procedure is generally not separately payable. Joint injections and cast application codes sit here. |
| 10-day (other minor procedures) | No preoperative period. Eleven days total — the procedure day plus the 10 days after it. |
| 90-day (major procedures) | Ninety-two days total — one day before, the procedure day, and the 90 days after. Most open surgery and most fracture care codes sit here. |
The package includes preoperative visits after the decision to operate, the procedure itself, postoperative visits related to recovery, dressing changes, suture removal, and complications that do not require a return to the operating room. That last clause is the one practices forget: managing a postoperative complication in the office is included, even when it costs you real time.
Two consequences follow. The global indicator for a code is a fact you can look up in the Medicare Physician Fee Schedule, not a rule of thumb. And included postoperative visits should still be documented and, where required, reported with CPT 99024, which indicates an evaluation and management service furnished during a postoperative period for a reason related to the original procedure. It pays nothing, but it is how the visit exists in the data.
Which modifiers matter most during an orthopedic global period?
Six modifiers do most of the work. Their definitions, as stated in the CMS Global Surgery Booklet, are below. Each one asserts that something falls outside the bundled package — and each needs documentation to prove it.
| Modifier | Definition | Orthopedic use in practice |
|---|---|---|
| 24 | Unrelated evaluation and management service by the same provider during a postoperative period | A patient six weeks out from a rotator cuff repair presents with a new knee complaint. The diagnosis must support the word “unrelated.” |
| 25 | Significant, separately identifiable evaluation and management service by the same provider on the day of a procedure | A knee pain workup leads to an injection the same day. The E/M note must stand on its own. |
| 57 | Decision for surgery — identifies the visit that results in the first decision to perform surgery | Used the day before or day of a major (90-day) procedure. CMS is explicit that it is not used with minor surgeries. |
| 58 | Staged or related procedure or service during the postoperative period | Planned prospectively or at the time of the original procedure — a planned hardware removal or staged reconstruction. |
| 78 | Unplanned return to the operating or procedure room by the same provider following the initial related procedure during the postoperative period | A postoperative hematoma requires evacuation. Bill the code for what was done on the return trip. |
| 79 | Unrelated procedure or service by the same provider during a postoperative period | Surgery on the contralateral limb during the first procedure’s global period. A new postoperative period starts. |
When should you bill fracture care instead of an evaluation and management visit?
Fracture care codes describe restorative treatment and carry their own global period — commonly 90 days for closed treatment codes such as CPT 25600 (closed treatment of a distal radial fracture without manipulation) and CPT 25605 (the same fracture with manipulation). Confirm the global indicator for the code you report. Choosing between fracture care and an E/M visit is a clinical decision, not a coding preference:
- Bill fracture care when your physician assumes restorative treatment and follow-up care for that fracture. The initial cast or splint is included in the fracture care code.
- Bill an E/M service and the casting code when your physician stabilizes the patient but is not assuming subsequent fracture care — for example, when the patient is referred on.
- Reapplication of a cast during the global period is separately reportable when medically necessary, because the fracture care code includes only the initial cast or splint, not subsequent replacements.
Because most fracture care codes are major procedures, the visit at which the decision to treat is made may be separately reportable with modifier 57. This is one of the most common places orthopedic practices leave money behind: the visit is furnished, documented, and then written off as bundled when it was not.
How should casting supplies and DME be handled?
Cast and splint application is a CPT service. Cast supplies are a separate HCPCS claim. Common examples:
| Code | Descriptor |
|---|---|
| CPT 29075 | Application, cast; elbow to finger (short arm) |
| CPT 29065 | Application, cast; shoulder to hand (long arm) |
| CPT 29125 | Application of short arm splint (forearm to hand); static |
| CPT 29405 | Application of short leg cast (below knee to toes) |
| CPT 29425 | Application of short leg cast (below knee to toes); walking or ambulatory type |
| HCPCS Q4010 | Cast supplies, short arm cast, adult (11 years +), fiberglass |
| HCPCS Q4038 | Cast supplies, short leg cast, adult (11 years +), fiberglass |
| HCPCS A4590 | Special casting material (e.g., fiberglass) |
Braces and boots dispensed from the office are durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), where custom-fitted versus off-the-shelf is a coding distinction with real dollars attached. HCPCS L4360 describes a pneumatic walking boot that is a prefabricated item trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise; HCPCS L4361 describes the same boot supplied off the shelf. Documentation has to support which one you did.
Practices billing Medicare for these items must be enrolled as DMEPOS suppliers and meet supplier standards. Claims commonly require the KX modifier — “requirements specified in the medical policy have been met” — plus right and left side modifiers and, where applicable, the NU modifier for new equipment. When a denial is expected, the GA modifier signals that a waiver of liability statement was issued as required by payer policy. These denials cluster tightly, which makes them well suited to a structured denial management and appeal workflow rather than one-off rework.
How should in-office imaging be billed?
Radiology has two components. The technical component covers the equipment, image capture, and staff; the professional component covers the physician’s interpretation and written report. When your practice owns the equipment and your physician interprets the study, you bill globally, with no component modifier. When only one component belongs to you, modifier 26 identifies the professional component and modifier TC the technical component.
The rule that gets practices in trouble is the report. A billable professional component requires a distinct, retrievable written interpretation. A line in the visit note reading “X-ray reviewed, no fracture” does not meet that standard, and an audit will treat the component as unsupported.
View counts matter too, because the code changes with them. CPT 73560 is a radiologic examination of the knee, 1 or 2 views; CPT 73562 is the same examination with 3 views; CPT 73564 is a complete knee examination with 4 or more views; CPT 73030 is a radiologic examination of the shoulder, complete, minimum of 2 views. If your technologists routinely capture more views than your coders bill, you are underbilling work you already did.
Joint procedures follow their own logic. CPT 20610 is arthrocentesis, aspiration, and/or injection of a major joint or bursa without ultrasound guidance; CPT 20611 is the same procedure with ultrasound guidance, with permanent recording and reporting. The image and the report are part of the code — without them, CPT 20611 is not supported.
What should you expect from orthopedic billing services?
Specialty knowledge is table stakes. What separates a billing partner from a claims processor is whether they close the loop between coding decisions and financial outcomes. Ask to see:
- Global period tracking. Which visits fell inside a global window, which carried a modifier, and which were written off?
- Modifier-level denial analysis. Denials on modifier 25 behave differently than denials on modifier 78; aggregate denial rates hide both.
- Charge capture for supplies and DME. Casting supplies and braces are dispensed at the point of care and are the easiest charges to lose entirely.
- Reporting you can use. A monthly view of the billing KPIs worth reviewing monthly, including days in A/R and clean claim rate.
Those capabilities are what our orthopedic surgeon medical billing service is built around. If you would rather test your current setup before changing it, global period leakage and unbilled post-operative work are among the largest findings that medical billing audit services routinely turn up in orthopedics.
Frequently asked questions
Can we bill an office visit during a 90-day global period?
Yes, when the visit is genuinely unrelated to the original procedure. Append modifier 24 and make sure the diagnosis and the note support that. Visits related to the original procedure — including complications that do not require a return to the operating room — are included in the global package.
What is the difference between modifier 58 and modifier 78?
Modifier 58 describes a staged or related procedure planned prospectively or at the time of the original procedure. Modifier 78 describes an unplanned return to the operating or procedure room for a related procedure. Modifier 79 describes an unrelated procedure and starts a new postoperative period.
Do we bill casting supplies separately from the cast application code?
Generally yes. The application code describes the professional service; HCPCS supply codes such as Q4010 and Q4038 describe the materials. Payer policies vary on which supply codes are recognized and in what quantity, so confirm each major contract.
Does our practice need to be a DMEPOS supplier to dispense braces?
To bill Medicare for DMEPOS items dispensed to beneficiaries, the practice must be enrolled as a DMEPOS supplier and meet the applicable supplier standards. Commercial requirements vary; some contracts exclude in-office DME entirely.
Verify current CPT, ICD-10, and payer requirements before billing.
Talk with a billing team that knows orthopedics
AMS Solutions has been a physician-founded medical billing company since 1992, with AAPC-certified coders and 100% U.S.-based staff working in HIPAA-compliant workflows from Dallas, Texas for practices nationwide. We work as a long-term partner rather than a vendor — which in orthopedics means understanding your global periods and your supply closet as well as your fee schedule. Request a free orthopedic billing consultation or reach out through our contact form. You can also call 866-973-2221.
