Fracture care: global package or itemized visit
A closed distal radius fracture can be reported two ways. The fracture care code, 25600 without manipulation or 25605 with manipulation, is a surgical package that pays for the reduction, the first cast and routine follow-up through the global period. The alternative is the E/M visit plus the cast application (29075 for a short arm cast) and supplies, with each later visit billed on its own.
The package fits when your surgeon will manage the fracture through healing. Itemizing fits when the patient was seen once and referred out, or when your office only applies a replacement cast. A recast inside the global is billable with the casting code while the E/M that day is not. We flag both paths at charge entry so the physician confirms the intent.
Modifiers 24, 25, 57, 58, 78 and 79 in the post-op window
The decision to operate, made at the visit before a major procedure, is billable with modifier 57 on the E/M. Before a minor procedure, the same visit carries modifier 25 and needs a documented problem beyond the decision itself. Swapping the two is the most common reason the visit is denied as included in the surgery.
Inside the global, an E/M for an unrelated problem takes modifier 24 and a diagnosis that plainly differs from the surgical one. A planned second stage, like hardware removal, is modifier 58. An unplanned return to the operating room is modifier 78 and pays at the intraoperative portion. A procedure on an unrelated body part is modifier 79 and starts its own global. Our coders read the operative note against the original surgery date before choosing.
Arthroplasty, arthroscopy and the NCCI bundling edits
Total knee arthroplasty (27447) and total hip arthroplasty (27130) are the highest-value professional claims in the practice and the ones most often held for authorization. Plans want conservative treatment and imaging documented, and the approval has to name the correct procedure, side and facility. Post-operative visits are inside the package, so the few claims that follow a joint replacement each need a modifier.
Arthroscopy is where the bundling edits bite. Medial and lateral meniscectomy in the same knee is one code, 29880, not two units of 29881. Debridement in the same compartment bundles into the meniscectomy under the NCCI pairs and cannot be separated with modifier 59 unless a different compartment is documented. In the shoulder, rotator cuff repair (29827) is often paired with subacromial decompression, the add-on 29826, which pays only alongside a primary shoulder arthroscopy.
Injections, viscosupplementation and in-office imaging
Large joint injections are reported with 20610, or 20611 when ultrasound guidance is used and a permanent image is saved to the record; 20611 without the stored image is the injection denial we see most on audit. Tendon sheath injections use 20550 and 20551, and the drug is billed on its own line with the J code and NDC.
Hyaluronan viscosupplementation, products such as J7325 and J7321, needs authorization for the drug even though the procedure code does not. Plans specify the covered product, injections per series and the interval between series, and a claim outside those rules denies for medical necessity rather than authorization. Office X-rays such as a shoulder series (73030) or knee series (73562) are billed globally when the practice owns the equipment and reads the film; when an outside radiologist reads, the practice bills TC and the reader bills 26.
Braces, casting supplies, therapy and workers’ compensation billing
Dispensing a knee orthosis (L1832) or wrist orthosis (L3908) from the office makes the practice a DMEPOS supplier, with its own standards: a written order, proof of delivery, and no separate brace payment when the payer treats it as part of a same-day procedure. Casting supplies are reported with Q codes by body part and material, and a fracture claim that omits the supply line leaves that work unpaid.
A practice with its own therapy department bills timed codes such as 97110 and 97140 in units governed by total timed minutes, not by how many exercises were performed. Workers’ compensation and auto liability claims follow the state fee schedule rather than the payer contract, require the claim number, date of injury and employer, and often demand a separate form and utilization-review approval. We keep a per-state checklist so these claims are complete on first submission.
How we take on orthopedic billing
We start with a free review of your accounts receivable, sorted by why claims are sitting: arthroplasty waiting on authorization, post-op visits missing a modifier, and comp claims aging past the carrier’s response window each need a different remedy. We work inside the practice management system and EHR you already use, our coders hold AAPC or AHIMA credentials, and a BAA is executed before any chart is shared.
The transition is a parallel run of two to four weeks in which your outgoing biller and our team code the same operative notes, and every disagreement is settled on the record so your modifier conventions and payer rules are written down. After the initial term the agreement is month-to-month, with a named account manager who knows your surgeons and your comp carriers.
