Comprehensive Overview of Orthopedic Medical Billing and Coding

Many healthcare organizations place a great deal of focus on Orthopedics. Thus, having reliable Orthopedic Medical Billing procedures is essential for obtaining reimbursement. By ensuring error-free EMRs and faster insurer approvals, the right systems and administrators may help you enhance your revenue cycle.

Compared to other specializations, Orthopedic Billing is complex and requires a thorough understanding of providers’ services. Nearly 35% of Orthopedic Surgery claims are incorrect, while 25% of those medical claims are denied. Such high denial rates may impair patient care and revenue while forcing your Orthopedic practice into collapse.

Orthopedic Medical Billing and Coding; An Overview

Orthopedic Billing services cover a wide range of provided services and procedures.  The Orthopedic medical billers must be conversant with coding, recognize the billing procedure, and understand the rules particular to each payor. The Orthopedic Biller/Coder is accountable for coding the procedures and diagnosis codes and works closely with the providers to educate and collect precise answers in order to code accurately. The purpose of this is to be proactive and to receive revenue as soon as possible. The Orthopedic billers also follow procedures for submitting claims, posting payments, tracking down rejections or denials, mastering medical billing software, confirming appropriate payment, and billing patients. Any in-house billing professional may find it challenging to keep up with these processes.

As a medical billing company with more than 15 years of experience, NEO MD is well versed in Medical Billing and Coding Services.  Our certified coders and professionals in Orthopedic Medical Billing are familiar with the complexities and nuances of the medical coding and billing industry.

Orthopedic Medical Billing Services
Orthopedic Medical Billing Services

What is Orthopedic Medical Billing?

It encompasses the entire claims-filing process, including ensuring that all supporting data is in order and that medical necessity is present. When it comes to Orthopedic Medical Billing and Coding, it’s also crucial to follow up on claims, make corrections, meet filing deadlines, and manage A/R collections.


Orthopedic surgeons are medical professionals that focus on the musculoskeletal system, which includes the bones, joints, ligaments, tendons, muscles, and other soft tissues that are necessary for movement and routine activities. These medical professionals handle both simple and complicated musculoskeletal diseases and injuries. Fractures, dislocations, and arthritis are a few examples of disorders.

Below are the common Orthopedic Diseases & conditions flanked by basic Orthopedic Surgeries and Procedures. 

Common Orthopedic Diseases & Conditions:

  • Fractures (Traumatic/Pathological/Open/Closed)
  • Tennis elbow
  • Joint dislocations
  • Plantar fasciitis
  • Sprains and strains
  • ACL tear
  • Rotator cuff tear
  • Osteoarthritis
  • Carpal/ Tarsal tunnel syndrome
  • Scoliosis, Kyphosis
  • Meniscus tear
  • Vertebral disorders and many more.

General Orthopedics Treatments & Procedures:

  • Joint fusion
  • Arthroscopic surgeries
  • Amputation
  • ORIF and advanced external fixation
  • Arthroplasty or joint replacements
  • Repair and reconstruction of torn ligaments and tendons
  • Craniotomy, burr hole
  • Spine surgeries, including discectomy, foraminotomy, laminectomy, and spinal fusion
  • Bone grafting and many more.

Orthopedic Medical Billing Process Flow, We Follow

We’ve given a full breakdown of the procedure in order to provide the finest Orthopedic Billing services. NEO MD offers the billing and coding services your facility needs to boost income, whether you’re processing claims for Orthopedic Surgery or billing for Orthopedic trauma treatment. Give us a chance to guide you through the special procedure flow we employ for Orthopedic Medical Billing services.

01. Execution of the Service Agreement

When you pick our services, we ensure that the necessary paperwork, such as the business partner agreement, is performed.

02. Project Allocation

As soon as the partners and NEO MD Medical Billing reach an agreement. We assign the project to a dedicated manager, skilled coders, and billers who will handle the whole process of Orthopedic Medical Billing.

03. Secure Channel for Client Data Transfer

In order to protect the security and privacy of the data and to provide simple access to the electronic health record (EHR) and document management system (DMS). Additionally, the client will send the clinical and insurance data using a secure FTP.

04. The Billing Services

Our AAPC Certified Professionals employ robust billing software to carry out Orthopedic coding tasks in accordance with HIPAA standards and have a solid understanding of the ICD-10, ICD-11, and DSM-5 systems.

05. Quality Assurance

Every piece of information in the claim documents will be carefully examined to see if it complies with HIPAA regulations and the insurance company’s particular requirements. We will submit the claims as soon as all conditions and procedures are satisfied.

06. Denial Management

Regardless of whether there is an error or missing data, if the payer returns claims, we will swiftly evaluate, validate, fix, and transmit the claim to guarantee reimbursement in the short turnaround time. 

07. Submission of Final Claims

We’ll submit the claim in the manner the insurance company has requested. To keep track of the data, we will ensure the digital submission of claims. To avoid unauthorized modifications and protect the confidentiality, the data will be transmitted over secure FTP

Orthopedic Medical Billing
Orthopedic Medical Billing

Eligibility and Verification

Be proactive in figuring out insurance verification and coverage, especially if prior insurance authorizations are necessary, as there are several medical reimbursement policies. The patient must sign an Advanced Beneficiary Notice (ABN) if Medicare does not cover the services. Processing medical bills can be challenging since several top commercial carriers, like United Health and the Blue Cross Group, have their own payment rules. Because of this, medical billing companies must invest the necessary time in mandatory negotiations with commercial carriers.

Orthopedic Medical Billing and Coding Guidelines

Orthopedic coding has its complexities, much like other specialties. In Orthopedics, coding denials often happen and are frequently the consequence of inadequate documentation. It’s best practice to code based on documentation rather than reimbursement because incomplete medical records might lead to problems. Numerous healthcare professionals forget to record important details, which can obstruct Orthopedic Medical Billing and lead to lost revenue. Many clinicians and internal teams struggle to keep up with the continuously changing payor requirements and medical coding standards. It is vital to provide frequent educational events for providers as well as professional coders and billers. 

NEO MD has qualified coders and experienced Orthopedic Medical Billing specialists that can ensure your clinic is prepared for ICD-10. To decrease denials and enhance your revenue cycle management, our certified coders utilize cutting-edge coding solutions and carry out routine audit checks. When offering professional coding services, it is crucial to comprehend how to use standard CPT and ICD-CM diagnosis coding and give codes that adhere to CMS guidelines.

You can also check coding guidelines for Knee pain Medical Billing.

There are various medical specializations that call for particular coding for billing, and even within some specialties, there may be several medical billing codes based on the treatment performed.

Orthopedic Medical Billing
Orthopedic Medical Billing

Medical billing services for Orthopedic Surgeries differ depending on the surgery being done. The musculoskeletal system, which consists of the bones, tendons, ligaments, and/or muscles, is the subject of Orthopedics in general. Depending on which branch of Orthopedics the surgery belongs to, the coding may vary. For instance, a pediatric Orthopedic office that performs a variety of treatments will need different coding services than an Orthopedic practice that does several operations for adults.

Medical billing codes for Orthopedic treatments vary following the guidelines outlined in the ICD-10-PCS, just like for other specialties. Medical billing experts may bill the appropriate therapies to a patient’s insurance provider using these particular codes, resulting in a more uniform billing and coding system.

Procedures for Tendons & Ligaments

The methods for the tendons and ligaments, such as PLC reconstruction, are still different. Repair procedures for such sections would start with “0L” and “0M,” respectively. It is common to submit Orthopedic Surgery claims in this way. This comprises:

  • Depending on the procedure employed, the code for a tendon repair in the right lower arm might be 0LQ50ZZ, 0LQ53ZZ, or 0LQ54ZZ.
  • The code for a ligament repair in the right lower arm could be 0MQ50ZZ, 0MQ53ZZ, or 0MQ54ZZ.

Character Designation

The character structure for procedures is as follows:

  1. The first character entitles the section in which the procedure falls in the ICD-10.
  2. The second character signifies the body system affected by the procedure.
  3. The root operation of the procedure determines the third character.
  4. In the fourth character, we recognize the body part affected by the procedure.
  5. The fifth character outlines the approach of the procedure.
  6. The sixth character describes the device being used.
  7. To make the coding process as straightforward as feasible, the seventh character gives any further qualifying information vital to the method.

What are modifiers, and why are they essential in Orthopedic Medical Billing?

Modifiers are just two-character designators that indicate how the procedure or service code should be applied to the claim. Modifiers have the ability to improve the accuracy and detail of a medical transaction’s record when used wisely. On the contrary, their improper utilization may result in investigations, refunds & fines (in rare cases), and claim denials.

Orthopedic practices require in-depth knowledge and the usage of code modifiers wherever feasible and authorized in order to generate the proper amount of revenue. Throughout the main procedure code, modifiers indicate changes to the procedure. Modifiers may affect reimbursement. Additionally, if employed improperly or not at all, they are the cause of claims failing to play or being denied when necessary. Both providers can use modifiers, with some intended solely for Ambulatory Surgical Centers and others for physician practices.

Orthopedic Medical Billing
Orthopedic Medical Billing

Top CPT codes used in Orthopedics billing:

  • Evaluation and Management: 99201 – 99499
  • Medicine: 90281 – 99199; 99500 – 99607
  • Anesthesia: 00100 – 01999; 99100 – 99140
  • Radiology: 70010 – 79999
  • Surgery: 10021 – 69990
  • Pathology and Laboratory: 80047 – 89398
  • Hand Surgery
  • CPT – 64721 – Neuroplasty (carpal tunnel release)
  • CPT – 25215 – Carpectomy; all bones of the proximal row
  • CPT – 11760 – Repair of Nail Bed
  • Carpal Tunnel Release – 64721
  • Endoscopic Carpal Tunnel Release – 29848
  • “Neuroplasty and/or transposition; median nerve at the carpal tunnel.”

You can also Read about CPT CODE 96372 & Its Reimbursement Guide.

Here is a precise table outlining when to utilize modifiers in Orthopedic procedures:

ModifierProcedureUnit (ASC/P)
-50Bilateral proceduresBoth
-51Multiple procedures(P)
-52Reduced services
-58Staged or related procedure or service by the same physician during the postoperative periodBoth
-59Distinct procedural serviceBoth
-73Discontinued outpatient hospital/ASC procedure before the administration of anesthesia(A)
-74Discontinued outpatient hospital/ASC procedure after the administration of anesthesia(A)
-76Repeat procedure or service by the same physicianBoth
-77Repeat procedure or service by another physicianBoth
-78Return to the OR for a related procedure during the postoperative periodBoth
-79Unrelated procedure or service by the same physician during the postoperative periodBoth
-RT & -LTRight Side and Left SideBoth
-TCTechnical componentBoth

How can NEO MD manage Orthopedic Medical Billing for their partner practices?

The processes involved in medical billing and coding can be very complex. Therefore, handling these processes internally might not be a smart move from an economic or strategic standpoint. Another onerous task for medical facilities is keeping up with the rules and regulations that are constantly evolving. Due to the industry’s quick evolution, Orthopedic Medical Billing and other emergency room coding are peculiar. So, outsourcing medical billing to NEO MD will pay off because our billers and coders are already excelling in the field.

Our committed team of medical billers and coders can assist you in expanding your practice. To ensure maximum reimbursement, our team closely follows all CMS Orthopedic Billing guidelines. The coding of each claim in real-time, quickly, accurately, and without mistakes, as well as an early evaluation to ensure claim eligibility, reduces the risk of claim denial and refusal. Top US revenue cycle management companies supervise many newly constructed healthcare facilities. 

Compared to other Revenue Cycle Management companies, NEO MD’s Orthopedic Billing services are consistently ranked as the best in the US.  NEO MD also provides for small practices, medium-sized, and big offices. Furthermore, we provide tailored billing services to practices in all US states. So, for acquiring our services, the healthcare facilities could find us the best Medical Billing company near me.

What Makes NEO MD the Best Orthopedic Billing Services Company?

NEO MD stood best among competitors in terms of providing good Revenue Cycle Management services to practices due to the following cores;

  • Our experts work hard to reduce your front-end denials by 20%.
  • Provide fortnightly financial and practice overviews 
  • Identify potential underover, and incorrect coding scenarios
  • Regular updates on coding compliance
  • Offer Provider & Staff Productivity Analysis
  • Refunds adjustment and Payment posting to improve the cash flow.
  • Use the latest technology and tools to ensure the accuracy of claims and faster collection.
  • Offer internal Medical Billing audits to uncover loopholes
  • Improve RCM system efficiency with a robust credentialing team. 
  • Out of Network Negotiations.
  • Offer Services that are easily scalable at all times 

We have consistently increased the collection rate (Orthopedic Medical Billing) for our clients.

Orthopedic Medical Billing
Orthopedic Medical Billing

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