The global surgical package
Most orthopedic surgery is paid as a package. Major procedures carry a 90-day global period; minor procedures carry 0 or 10 days. The package covers pre-operative visits the day before and the day of surgery, the procedure itself, and routine post-operative care during the global period. A visit at which the decision for major surgery is made is billed separately with modifier 57. Revenue is lost in two directions: post-operative visits billed as if they were new problems are denied, and genuinely separate services inside a global period go unbilled because staff assume everything is included.
| Situation inside a global period | Modifier |
|---|---|
| Visit for a problem unrelated to the surgery | 24 |
| Decision for major surgery the day before or day of | 57 |
| Planned or staged procedure, or more extensive than the original | 58 |
| Unplanned return to the operating room for a related problem | 78 |
| Unrelated procedure by the same physician | 79 |
Laterality, multiple procedures and assistants
Orthopedic claims depend on modifiers that describe where and how much: RT and LT, finger and toe modifiers (F1–F9, FA, T1–T9, TA), bilateral modifier 50, and multiple-procedure reporting so the payer applies its reduction to the right line. Arthroscopy and open procedures on the same joint are a frequent source of NCCI edits. Assistant-at-surgery modifiers (80, 82, AS) are payable only for procedures where the payer allows an assistant.
Injections and drugs
Joint injections are billed with the procedure code, the drug’s HCPCS code and the number of units given. Units must match the drug’s HCPCS description, and image guidance is bundled into some injection codes but separately reportable with others. Hyaluronic acid and other high-cost drugs frequently need prior authorization and have frequency limits under local coverage determinations.
Durable medical equipment
Braces, splints and other DME supplied by the practice are billed with HCPCS L-codes. For Medicare, the practice must be enrolled as a DMEPOS supplier and meet supplier standards, and some items require specific documentation such as a written order and proof of delivery. Off-the-shelf and custom-fitted items use different codes.
Workers’ compensation and auto injury
Injury cases follow different rules from health insurance: state fee schedules, claim numbers and adjuster approvals for workers’ compensation, and personal injury protection or liability payers for auto cases. Bills sent to the patient’s health plan instead of the responsible carrier are denied for coordination of benefits. We confirm the responsible payer at intake and follow each state’s billing forms and attachment rules. For approvals before surgery and imaging, see prior authorization services; for orthopedic procedures performed in a surgery center, see ASC billing.