Medical Billing

Understand CPT Codes for Orthopedic Medical Billing and Guidelines

Understand CPT Codes for orthopedic medical billing and guidelines

Like every medical practice, managing and running revenue management cycles smoothly are the essential functions of orthopedics and any other medical practice alike. By managing your billing practices effectively, revenue will continue to reach on time while minimizing delays and improving cash flow limitations.

When it comes to orthopedic medical billing, orthopedic practitioners need to consider several things in mind in order to bill correctly and reduce the significant chances of claim denials.

The article discusses five guidelines for practitioners that assist them in managing their revenue resourcefully.

Effective Guidelines for Orthopedic Medical Billing

1. Insurance Coverage Verification

One of the most important aspects of medical billing is to ensure and verify all the insurance-related elements of orthopedic billing. An orthopedic billing should provide services to patients who are pre-authorized and have verified insurance coverage. In addition, they also need to check with the insurers first, whether they cover the services expected to provide.

Effective guidelines for orthopedic medical billing

Understand the insurance policy that payers send you and determine if the policy covers the services and kinds of treatment you are providing. Verifying insurance coverage, in the beginning, will automatically resolve claim denials and reimbursement issues later.

2. Confirm Patient Information

It may seem like an obvious step in any medical billing practice, but mentioning the importance of this step becomes crucial sometimes. Always double-check the spelling, address, contact info, demographics, and other associated information about patients to be correct. A single overlooked spelling error can be a cause of claim denial. Instruct your administrative staff to go through every detail vigilantly and ensure that every piece of information that they are sending ahead in the claims is accurate to process.

3. Timely Claim Filing

Another mistake that practitioners often make is not filing their billable claims on time, either because they are too busy handling patients or don’t have proper claiming resources. Creating a standard process by adhering to the regulated procedure and ensuring that the popular metrics are followed, can significantly improve the claims filing process within the given time. In addition, it is also important to be aware of the claim filing timelines and limitations that you need to adhere to according to the tailored policies that many insurance payers possess. Managing and filing claims on time with taking accurate measures will segregate between the denied and billed claims easily.

4. Specific Coding as much as possible

Many times, claims are denied just because they are not specifically coded. Not only does your practice need to have all the information about codes and what diagnosis it covers to justify the coding in your claims, but you also have to make sure that the codes you are using are correct against the analysis you are mentioning. The upgraded ICD-10 codes are more specific and require providers to code accurately to be paid timely. This means that if you don’t meet the criteria of the ICD-10 and CMS procedure and your claims are not compliant with the requirements, then your claims will not be paid completely for the services you rendered. Make sure that your billing staff is properly equipped with the essential knowledge and resources to document the claim codes efficiently.

5. Outsource when needed

Several times, when you need to cut the billing costs, might be from additional efforts in hiring a team of orthopedic medical billing experts, providing them additional and needful resources, managing denied claims by resubmitting and reclaiming, etc., outsourcing can be the best option.

It will not only save your time and make you stress-free, but also resolve many billing and claiming problems that might be resulting in denied claims. Outsourcing can expedite the claiming and billing process that may be delayed due to in-house staff illness, employee turnover, and vacations. All in all, practices that are partnered with the experts of orthopedic medical billing and credentialing companies remain a step ahead in managing account receivable, lower overhead costs, increased revenues, and profitability.

It is, however, imperative that you get paid for the efforts you are putting in to provide medical services. To make sure that your practice is being paid fairly, start compiling and filing your claims timely.

CPT Codes used in the Orthopedic Medical Billing

CPT codes used in the orthopedic medical billing

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

Modifiers of Orthopedic Billing and When to use them

Modifiers are basically a two-character code that modifies the meaning of CPT codes and make the procedure more elaborated for the claims. When they are used, they put an extensive accuracy in details to record in the claims so reimbursements would take place easily. However, if they are used incorrectly, the consequences can be severe resulting in fines and refunds, claim denials, and in many serious cases, investigations.

They are used in two different code levels – Level I and Level II;

Level I – Modifiers of Level I are specifically called CPT modifiers and are numeric codes regulated by AMA manually. They support additional information and provide extra details of services and treatments offered to the patient.

Level II – Modifiers of Level II are HCPCS Modifiers and are alphanumeric two-digit characters. They range from AA to VP and are updated by the Centers for Medicare and Medicaid Services – CMS annually.



Unit (ASC/P)


Bilateral procedures



Multiple procedures



Reduced services


Staged or related procedure or service by the same physician during the postoperative period



Distinct procedural service



Discontinued outpatient hospital/ASC procedure prior to the administration of anesthesia



Discontinued outpatient hospital/ASC procedure after the administration of anesthesia



Repeat procedure or service by the same physician



Repeat procedure or service by another physician



Return to the OR for a related procedure during the postoperative period



Unrelated procedure or service by the same physician during the postoperative period


-RT & -LT

Right Side and Left Side



Technical component