Orthopedic medical billing through the global period

Orthopedic medical billing is shaped by the surgical global period: after a major procedure, related care for 90 days is bundled into the surgical fee, and only correctly modified claims outside that bundle pay. Around the global period sit the laterality and distinct-procedure modifiers that paired joints require, prior authorization for imaging and surgery, and a workers compensation book with claim numbers, adjusters, and state fee schedules. Flexbone runs this work with agents inside your EHR and billing system, from eligibility through denial follow-up.

How do surgical global periods affect orthopedic billing?

A global period bundles the surgery and its routine follow-up into one fee. Major procedures, joint replacement and spine fusion among them, carry a 90-day global period under the Medicare fee schedule; minor procedures carry 0 or 10 days. During the period, related evaluation and management visits are not separately payable, and the billable exceptions ride on modifiers. Modifier 24 marks an unrelated E/M visit during the global period. Modifier 25 marks a significant, separately identifiable E/M on the day of a procedure. Modifier 57 marks the visit where the decision for surgery was made. Modifiers 58, 78, and 79 distinguish staged procedures, returns to the operating room, and unrelated procedures. A missed modifier either forfeits a payable visit or triggers a denial, and both are common in high-volume surgical groups. The orthopedics billing explainer covers the global period rules in more depth.

How are modifiers 59, RT, and LT used in orthopedic billing?

Modifier 59 marks a distinct procedural service. It tells the payer that two procedures normally bundled by NCCI edits were performed at separate sites or sessions, and Medicare prefers the more specific X modifiers, XE, XS, XP, and XU, where they apply. The operative note must support the distinction. RT and LT mark laterality, and in a specialty built on paired joints they appear on injections, imaging, and surgery alike. Laterality errors are mechanical and expensive: a claim without the modifier, or a claim whose side contradicts the authorization or the operative note, denies on a mismatch that a pre-submission check catches.

How do prior authorization and workers compensation claims work in orthopedics?

Authorization gates orthopedics twice: the advanced imaging that supports the surgical decision, and the surgery itself. MRI runs through radiology benefit managers on many plans, and joint replacement, spine procedures, and arthroscopy carry surgical authorization with documented conservative care. The orthopedic, spine, and pain PA page covers the criteria. The administrative load is measurable: an AMA survey found physicians complete about 39 prior authorizations per week, roughly 13 hours of practice time. Workers compensation adds a second billing universe for the same injuries. Claims bill to the carrier under a claim number, follow state fee schedules rather than contracted rates, and carry attachments, operative notes and progress reports, that group health claims do not. Billing the health plan when a comp claim exists, or the reverse, denies and restarts the clock.

How does Flexbone run orthopedic billing?

Flexbone deploys browser and voice agents across the orthopedic revenue cycle. Agents verify eligibility and identify workers compensation coverage up front, submit and track the imaging and surgical authorizations, check laterality and authorization agreement before submission, and work the denial queue by CARC code inside your EHR and billing system. The patient-facing side, surgical scheduling calls and post-operative follow-up, is covered on the orthopedic calls page. Results write back with an audit trail, and exceptions route to your billers with context.