Orthopedic Billing Services: Global Period Traps, Surgical Bundling Rules, and the Modifier Errors That Cost Practices Thousands

By Medtransic | February 15, 2026 | 17 min read | Updated: February 15, 2026

Quick Summary: Orthopedic billing spans surgical procedures, fracture care, joint injections, implant pass-throughs, and post-operative management — each governed by global period rules, NCCI bundling edits, and laterality modifiers that general billing companies consistently get wrong. The result is an estimated 7 to 12 percent of annual revenue lost to preventable coding errors.

At Medtransic, orthopedic billing is the specialty where surgical complexity meets the most rigid billing rules in medicine. Every major orthopedic surgery — joint replacements, spinal fusions, ACL reconstructions, rotator cuff repairs — carries a 90-day global period that bundles all pre-operative and post-operative care into a single payment. Bill a post-op visit separately during that window and the claim is denied. Miss a billable service that falls outside the global package and the revenue is gone.

But the global period is only one layer. Orthopedic practices also navigate laterality modifiers on every bilateral procedure, NCCI bundling edits that change which arthroscopic codes can be billed together, implant pass-through reimbursement that varies by facility type, and workers compensation claims that operate under entirely different fee schedules and authorization rules than commercial insurance. A general billing company treating orthopedic claims like primary care E/M visits will leave 7 to 12 percent of your annual revenue on the table.

This guide covers the coding rules, global period logic, modifier requirements, and payer-specific traps that define orthopedic medical billing — and what your billing company should be doing to capture every dollar your practice earns.

Why Orthopedic Billing Overwhelms General Billing Companies

Orthopedic practices generate revenue across a wider range of service types than almost any other specialty. A single practice may perform high-volume office visits and injections, outpatient arthroscopic procedures, major inpatient surgeries, post-operative rehabilitation management, DME prescriptions, and imaging interpretation — each with different coding rules, different payer requirements, and different reimbursement structures.

The fundamental challenge is that orthopedic surgery billing is built on the global surgical package — a concept that does not exist in most other specialties. When a surgeon performs a total knee replacement (CPT 27447), the reimbursement covers the surgery itself, one day of pre-operative care, and 90 days of post-operative follow-up visits. Every service during that 90-day window must be evaluated against the global package: is it included (not separately billable), or does it qualify for separate billing with the correct modifier? Getting this wrong in either direction — billing for included services or failing to bill for excluded services — costs practices thousands per surgeon per year.

Medtransic assigns dedicated orthopedic billing specialists to every musculoskeletal practice we serve because this specialty cannot be handled by generalists. Our orthopedic coding team reads operative reports, tracks global periods by patient, and applies modifier logic that reflects both CMS rules and payer-specific variations.

Orthopedic Surgery CPT Codes That Drive Revenue

Orthopedic CPT codes span the entire 20000-29999 musculoskeletal range plus evaluation and management, radiology, and medicine codes. The highest-revenue procedures require the most precise coding. For a broader reference, see our CPT codes cheat sheet.

Joint Replacement and Reconstruction

Arthroscopy

Spine Surgery

Spine surgery coding is among the most complex in all of medicine — sharing many of the same spinal procedure coding challenges encountered in pain management billing. A single posterior lumbar fusion may involve the fusion code (22612), instrumentation codes (22840-22848), bone graft codes (20930-20938), and intervertebral device codes (22853-22859) — each billed separately with specific documentation requirements. Missing any component is leaving revenue on the table. Billing an incorrect combination triggers bundling denials. Medtransic's spine coding specialists review every operative report against the full code family to ensure complete and compliant charge capture.

The Global Period: The Most Misunderstood Rule in Orthopedic Billing

The global surgical period is the single most important concept in orthopedic billing. Every major orthopedic surgery carries a global period during which pre-operative and post-operative services are bundled into the surgical fee. Understanding what is included versus what can be billed separately during the global window is the difference between accurate billing and systemic revenue loss.

Global Period Categories

What IS Included in the Global Period (Not Separately Billable)

What IS NOT Included (Can Be Billed Separately With Correct Modifier)

Fracture Care Billing: Open vs. Closed, Initial vs. Subsequent

Fracture care is one of the highest-volume revenue streams for orthopedic practices and one of the most error-prone areas of orthopedic medical billing. The coding depends on three variables that must all be documented and selected correctly: fracture type (open vs. closed), treatment type (with or without manipulation), and treatment setting (initial vs. subsequent encounter).

Fracture Treatment Code Logic

The ICD-10 coding for fractures adds another layer of complexity. Each fracture code requires a 7th character indicating encounter type: A (initial encounter), D (subsequent encounter for routine healing), G (subsequent encounter for delayed healing), K (subsequent encounter for nonunion), P (subsequent encounter for malunion), and S (sequela). Using the wrong 7th character — particularly billing an initial encounter code on a follow-up visit — triggers denials and audit flags. Medtransic's claim submission process validates the 7th character against the encounter type on every fracture claim.

Joint Injection Coding: Guided vs. Unguided and the Bundling Traps

Joint and soft tissue injections are among the most frequently performed — and most frequently miscoded — orthopedic procedures. The coding depends on the joint size, whether imaging guidance was used, and whether the injection was performed on the same day as an E/M service.

For practices performing high volumes of ultrasound-guided injections, the transition from 20610 to 20611 represents a significant revenue opportunity. Ultrasound-guided injections (20611) reimburse approximately 30-40% more than unguided injections (20610) and are increasingly considered the standard of care for accuracy. Practices that have invested in point-of-care ultrasound should ensure every guided injection is coded as 20611 — not 20610 with a separate 76942 (which bundles and is denied).

Implant and Device Billing: The Pass-Through Revenue Most Practices Miss

Orthopedic surgeries frequently involve high-cost implants — joint prostheses, spinal hardware, plates, screws, and fixation devices. How these implants are billed depends entirely on the setting where the surgery is performed, and getting this wrong is one of the largest revenue leaks in orthopedic billing.

For orthopedic practices with ASC ownership or affiliation, implant pass-through billing is a major revenue driver that requires specialized billing knowledge. The practice must track which implants qualify for separate reimbursement under current CMS and commercial payer rules, bill the correct HCPCS codes with supporting documentation (invoice, manufacturer, device identifier), and reconcile implant costs against reimbursement to ensure the ASC is not losing money on high-cost devices. Medtransic's orthopedic billing team manages implant tracking and pass-through billing for ASC-affiliated practices.

Modifier Rules That Make or Break Orthopedic Claims

Orthopedic billing uses more modifiers more frequently than almost any other specialty. Between laterality, global period exceptions, multiple procedures, bilateral surgeries, and assistant surgeon requirements, nearly every orthopedic claim requires at least one modifier — and many require two or three. For a complete reference, see our medical billing modifiers guide.

The -22 modifier is particularly under-utilized in orthopedic surgery. When a surgeon documents significantly increased complexity — revision cases with extensive adhesions, morbidly obese patients requiring modified approaches, intraoperative complications managed successfully — modifier -22 can increase reimbursement by 20 to 30%. But it requires a cover letter explaining the additional work, and not every payer honors it. Medtransic identifies -22 opportunities during operative report review and prepares the supporting documentation for submission.

The 7 Most Common Orthopedic Billing Denials (and How to Prevent Them)

Orthopedic claim denials follow predictable patterns. Here are the seven categories that account for the majority of lost revenue, and how Medtransic's denial management process prevents each one.

1. Services Billed During the Global Period Without Modifier

The most frequent orthopedic denial. A post-operative visit or procedure is billed during the 90-day global window without the appropriate modifier (-24, -58, -78, or -79) to indicate it falls outside the global package. Prevention: track every patient's active global periods and validate every claim against them before submission.

2. Prior Authorization Not Obtained for Surgery

Joint replacements, spinal fusions, arthroscopic procedures, and advanced imaging (MRI, CT) nearly always require prior authorization. Performing surgery without authorization results in complete claim denial. Prevention: initiate authorization requests immediately upon surgical scheduling and confirm approval before the procedure date.

3. Unbundling Errors on Arthroscopy Claims

Billing multiple arthroscopic procedure codes that NCCI edits consider bundled — such as diagnostic arthroscopy (29870) with a surgical arthroscopy, or separate debridement codes with a more comprehensive procedure. Prevention: validate every multi-code arthroscopy claim against current NCCI edits.

4. Laterality Modifier Missing

Claims for extremity procedures submitted without -RT or -LT modifier. Some payers also require laterality modifiers on diagnostic imaging codes. Prevention: enforce laterality documentation requirements at the point of charge capture and validate modifier presence before submission.

5. Open vs. Arthroscopic Code Mismatch

Billing an open procedure code (23412 — open rotator cuff repair) when the operative report documents an arthroscopic approach (29827 — arthroscopic rotator cuff repair), or vice versa. This creates a code-to-documentation mismatch that payers deny on audit. Prevention: compare the billed CPT code against the operative report's description of surgical approach on every surgical claim.

6. Fracture Care 7th Character Error

Using the initial encounter 7th character (A) on a follow-up fracture visit, or using the subsequent encounter character (D) on the first treatment. The ICD-10 7th character must match the encounter type documented in the chart. Prevention: verify encounter type alignment on every fracture claim.

7. Medical Necessity Documentation Insufficient

Payers deny surgical claims when the documentation does not establish that conservative treatment was attempted and failed before surgical intervention. Joint replacements typically require documented evidence of physical therapy, anti-inflammatory medications, and injection therapy before surgery is authorized. Prevention: ensure the surgeon's documentation includes the conservative treatment history and Medtransic's verification team confirms medical necessity requirements by payer before scheduling.

Workers Compensation and Personal Injury: The Orthopedic Revenue Stream That Requires Different Billing

Orthopedic practices treat a significant volume of workers compensation and personal injury cases — often 15 to 30% of total patient volume. These cases operate under entirely different billing rules than commercial insurance and require specialized handling that general billing companies frequently lack.

Personal injury and auto accident cases add another layer: billing against auto insurance policies, coordinating with attorneys on lien-based billing, and managing the extended timeline (some PI cases take 1-3 years to resolve). Medtransic's accounts receivable management includes dedicated workers compensation and personal injury follow-up workflows that account for the longer payment cycles and different authorization processes these cases require.

What to Demand From an Orthopedic Billing Company

Orthopedic billing demands capabilities that go far beyond standard revenue cycle management. When evaluating an orthopedic medical billing company, demand evidence of these specific competencies.

At Medtransic, our orthopedic billing clients see clean claim rates above 96%, denial rates below 5%, and average days in AR under 28 days — results driven by our comprehensive revenue cycle management methodology. We assign certified orthopedic coders to every musculoskeletal practice, track global periods at the patient level, and review every operative report for complete charge capture — including modifier -22 opportunities, missed add-on codes, and implant pass-through eligibility.