What is Orthopedic Coding?
Orthopedics focuses on the diagnosis, treatment, prevention and rehabilitation of disorders, injuries, and conditions affecting the musculoskeletal system encompassing bones, joints, tendons, muscles, and nerves. The complex nature of the procedures, the frequent changes in the coding and payer guidelines, and the demand for an in-depth understanding of the anatomy and medical terminology makes orthopedics a complex specialty.
How to Use this Guide
This cheat sheet provides a brief reference for the commonly made mistakes, commonly used CPT and ICD-10-CM codes, and modifiers in the ortho specialty. It also serves as an effective educational resource for new coders and billers by providing a quick overview of the essential information.
Common Mistakes in Orthopedic Medical Billing
Bundling Errors
Certain procedures and services are considered part of a single comprehensive service and must not be billed separately. Unbundling refers to the incorrect practice of coding and billing services that should be bundled into a single CPT code. Unbundling can lead to overpayment and is considered fraudulent. Bundling of services is guided by rules and guidelines to prevent overbilling and ensure healthcare providers are reimbursed appropriately for the services they provide. CMS and NCCI Edits provide comprehensive guidelines and code edits to avoid improper bundling and overpayment of services.
Not Verifying Medical Insurance
Failing to always check a patient’s insurance could lead to denied claims and unexpected bills for patients. You should always confirm coverage details before services are provided to avoid financial mishaps.
Payer Guidelines
Payer guidelines are critical to orthopedic coding. They dictate how a service must be documented, coded, and billed. They also promote compliance and effective reimbursement. Medical necessity and prior authorization are the two most important payer concepts that determine whether to pay or deny the procedure or service performed by the provider. Payer guidelines also influence the reimbursement rates for specific procedures and services. The payer policies for Medicare and private payers may vary significantly thereby affecting how practices manage their services and billing. A thorough understanding of the payer policy goes a long way in ensuring proper reimbursement of the services that can otherwise be denied.
Inappropriate Documentation
Accurate documentation is the key for ensuring proper reimbursement, compliance, and maintaining the integrity of the orthopedic practice. Inaccurate or insufficient documentation can result in unnecessary claim denials or delayed payments. This can disrupt the practice’s cash flow and collection targets. Documentation inefficiencies can also increase the risk of payer and CMS audits. It can also have a negative impact on patient care quality and potential legal liability for malpractice.
Not Coding to the Highest Degree of Specificity
Accurate reimbursement, reduction in claim denials, accurate quality reporting and performance metrics, improved patient care, and meeting compliance and regulatory requirements are directly linked with coding the diagnoses to the highest degree of specificity. Providers must be queried if the adequate documentation is not provided in the medical record.
Failure to Submit Updated and New Codes
CPT and ICD-10-CM codes undergo deletions and revisions on an annual basis. Healthcare professionals must stay current with the current coding guidelines and updates to ensure accurate and compliant coding and billing of claims.
Incorrect Modifiers
Modifiers provide additional information about a service or procedure without changing the meaning of the service or procedure performed by the provider. Payers have strict guidelines on the use of modifiers. Incorrect or inappropriate modifiers can lead to claim denials or spark audits by regulatory bodies.
Upcoding/Downcoding E&M Services
- Upcoding – upcoding occurs when a higher-level of E&M service code is assigned than is justified by the provider documentation or patient encounter. Example – billing for a level 4 service when the actual patient care documented supports a lower level of care (level 3).
- Downcoding – downcoding occurs when a lower-level of E&M service code is assigned than is justified by the provider documentation or patient encounter. Example – billing a level 4 service when the actual patient care warrants a level 5 service.
Upcoding and downcoding can have a serious impact on the financial and legal health of the practice. Coders must apply the most updated E&M guidelines and submit the most appropriate E&M level CPT codes as warranted by the patient encounter documentation.
Where Can I Get a List of CPT Codes?
The annually updated list of CPT and HCPCS codesets is available from the Centers for Medicare and Medicaid Services.
Top 25 CPT Codes
| Procedure | CPT Code |
| ACL reconstruction | 29888 |
| Achilles Tendon Repair | 29888 |
| Arthrocentesis aspiration | 20610 |
| Arthroscopy, knee | 29881 |
| Arthroscopy, shoulder | 29827 |
| Arthroscopy, hip | 29862 |
| Bunion Surgery | 28296 |
| Carpal Tunnel Release | 64721 |
| Disc Replacement | 22857 |
| Fracture Repair (various) | 25600 |
| Ganglion Cyst Removal | 20612 |
| Hammer Toe Correction | 28285 |
| Reconstructive Surgery, hand | 26356 |
| Hip Resurfacing | 27130 |
| Kyphoplasty | 22513 |
| Laminectomy | 63047 |
| Lumbar Spinal Fusion | 22633 |
| Meniscectomy or Meniscus Repair | 29881 |
| Osteotomy | 27446 |
| Plantar Fasciitis Surgery | 28060 |
| Rotator Cuff Repair | 29827 |
| Spinal Decompression | 63030 |
| Total Hip Replacement | 27130 |
| Total Knee Replacement | 27447 |
Common Modifiers
Modifier -RT and -LT
These are laterality modifiers that specify whether a procedure was performed on the right or the left side of the patient’s body. A total knee replacement performed on the right side would be billed with 27447-RT.
Modifier -59
This is appended with a CPT procedure code to indicate that the procedure is distinct from other services performed either at the same setting or on the same day. It is used in orthopedic surgery coding to unbundle procedures which could otherwise be denied as an integral part of a major surgery or procedure. One of the most sought after modifiers in a regulatory audit.
Modifier -50
This indicates “bilateral procedure.” when the same procedure is performed on both sides of the patient body and if there are no specific codes to denote the service so performed on each side, modifier -50 is appended with the procedure so performed. If a total knee replacement is performed bilaterally, CPT 27447-50 can be billed to denote the bilateral nature of the procedure.
Modifier -51
This modifier is used when multiple surgical procedures are performed on the same operative session. All minor surgical procedures are appended with modifier -51. This modifier must not be appended with the major surgical procedure CPT in the same operative session.
Modifier – 78
This modifier is appended to the CPT code when the patient’s condition necessitates an unplanned return to the operating room for a related procedure during a pre-existing post-operative period. Example – a patient undergoes a total hip replacement on his right hip. During the postoperative period the patient has a fall and experiences dislocation of the prosthetic hip joint and is required to undergo a closed reduction to realign the dislocated prosthetic hip joint. This return to the operating room warrants to be billed with CPT 27253-78-RT.
All About Modifier 25
Modifier 25 is used to indicate that on the day a procedure or service was performed, the patient’s condition required a significant, separately identifiable evaluation and management (E/M) service. Otherwise the E&M service can be denied by the payer as bundled into the procedure performed on the same day in the same office setting. Example – a patient with knee pain presents to the orthopedic clinic for an initial appointment. During the visit, the provider evaluates the patient’s knee pain, discusses treatment options, and decides to perform a knee joint injection to alleviate the pain. Modifier -25 is appended to the E&M code to indicate to the payer that the E&M visit was a significantly, separately identifiable service provided on the same day as the knee joint injection.
Difference Between Modifier 25 and Modifier 57
Modifier 25:
- Applied to E/M services provided on the same day as a minor procedure when the E/M service is significantly separate from the procedure.
- Use Modifier 25 when performing a minor procedure on the same day as a significant, separate E/M service.
Modifier 57:
- Used to indicate that an E/M service resulted in the initial decision to perform a major surgery (usually one with a 90-day global period). It’s used when the decision for surgery is made during the E/M service, and the surgery takes place the same day or soon thereafter.
- Use Modifier 57 when the E/M service results in the decision to perform a major surgery immediately or soon after the evaluation.
Expert Healthcare Guidance at HIS
Healthcare Information Services (HIS) is a physician management company, specializing in revenue cycle management and consulting services. Our team has over three decades of experience working with orthopedic and radiology practices across the United States. We create customized solutions for our clients, as well as offer education, training, and updates related to the healthcare industry including CMS coding changes. If you’d like to learn more about our services or if you have any questions, please contact us today.