Orthopedic billing is surgical billing. And surgical billing has one rule that general billers routinely get wrong: the global period.
When a surgeon performs a procedure, Medicare and most commercial payers bundle the post-operative care into the surgical payment for a defined period — 10 days for minor procedures, 90 days for major ones. Any E/M visit during the global period that relates to the surgery is not separately billable. Bill it without the right modifier and it denies. Apply the wrong modifier and it denies. Don’t track which patients are in active global periods and you’ll bill incorrectly on dozens of claims before anyone catches it.
Add to that the prior authorization burden — orthopedic surgeries, MRIs, and physical therapy all require auth in most commercial plans — and the modifier complexity on bilateral and multiple-procedure claims, and you have a specialty that generates more billing errors per case than almost any other.
The Three Billing Problems That Hit Orthopedic Practices Hardest
1. Global Period Violations
The most common orthopedic billing error: billing a follow-up visit during the global period without the modifier that establishes it as a separately payable service. Modifier -24 applies to unrelated E/M visits during the global period. Modifier -79 applies to unrelated procedures. Modifier -78 applies to return-to-OR for related complications. Without the right modifier, every one of those claims denies.
Tracking global periods across a practice seeing 30 or 40 surgical patients in various stages of post-op care requires a daily active patient list. Most practices don’t have one.
2. Implant and Device Charge Capture
Orthopedic surgeries frequently involve implants — screws, plates, joint replacement components — that represent significant supply costs. When those charges aren’t captured and billed correctly, the practice absorbs the cost without reimbursement. Implant charge capture requires coordination between the OR, the billing team, and the implant vendor invoice — a workflow that breaks down consistently in practices without a dedicated process.
3. Prior Authorization for Surgical Cases
Total joint replacements, spine surgeries, and many arthroscopic procedures require prior authorization. The authorization process in orthopedics often requires imaging reports, conservative treatment documentation showing the patient has tried and failed less invasive approaches, and surgical necessity letters. Missing any of these components at submission delays the auth and — if the surgery proceeds without it — generates a denial that may not be fully recoverable.
An orthopedic group with three surgeons came to us after their billing coordinator went on leave and a temporary replacement had been handling claims for two months.
We audited 90 days of claims in their NextGen system. The global period picture was immediate: 23 post-op visits had been billed without modifiers during active global periods. Some were clearly related to the surgery. Some were for unrelated conditions that were legitimately separately billable — but the modifier wasn’t there, so they had all denied the same way.
We also found 11 surgical cases where implant charges hadn’t been captured. The procedures had been billed. The implant supply costs had not. Each one represented a direct revenue loss.
We assigned a dedicated orthopedic billing specialist. Global period tracking was built as a daily active patient list — every post-op patient, their procedure date, their global period end date, and the modifier required for any visit during that period. Implant charge capture was implemented as a same-day workflow tied to the OR schedule. For the denial backlog, we worked every recoverable claim: related post-op visits were corrected with the right modifier and resubmitted, unrelated visits had -24 or -79 applied and resubmitted. The practice recovered $44,000 in previously denied claims within the timely filing window.
Common Orthopedic Billing Denial Codes
| Denial Code | Reason | Fix |
|---|---|---|
| CO-97 | Service included in global period | Apply -24, -78, or -79 modifier to establish separate payability |
| CO-4 | Modifier missing or incorrect | Verify -50, -RT/-LT, -59 on bilateral and multiple procedure claims |
| CO-15 | Prior auth invalid or not obtained | Build auth documentation with imaging, conservative treatment history, surgical necessity |
| CO-11 | Diagnosis not consistent with procedure | ICD-10 specificity — laterality, joint site, acute vs chronic required |
| CO-B7 | Provider not credentialed with plan | Verify credentialing for all surgeons across all active commercial plans quarterly |
Frequently Asked Questions
How do you manage global period billing across a multi-surgeon practice?
We maintain a daily active global period list — every surgical patient, their procedure date, their global period end date (10 or 90 days depending on procedure), and the correct modifier for any visit that occurs during that period. Before any E/M claim is submitted for a post-op patient, it’s checked against the list. The free RCM manager audits the list weekly.
How do you handle implant charge capture?
We build implant charge capture as a same-day workflow tied to the OR schedule. The moment a surgical case closes, we reconcile the implant usage against the vendor invoice and add the charges to the claim before it’s submitted. Nothing waits for someone to remember to add it later.
What EHR systems do your orthopedic billers support?
NextGen, Epic, athenahealth, AdvancedMD, and Modernizing Medicine (EMA). Our billers know the global period tracking, surgical charge capture, and prior auth workflows in each platform.
Global period violations are the most preventable errors in orthopedic billing. The right modifier was always the answer — someone just needed to be tracking which patients needed it.
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