Orthopedic Billing and Coding Guidelines

Orthopedic billing and coding is a very complex process. If you aren’t trained in billing and coding practices, then you will face numerous challenges. Each year, hospitals and practices lose billions of dollars just because of minor mistakes in the billing process.

Plus, the billing regulations are constantly changing, which makes the process even more difficult. These changes can be related to anything, such as frequent updates to payer guidelines and strict compliance requirements. In 2025, 270 new codes were introduced and 112 codes were revised.

That’s why it is essential to understand the correct use of CPT codes and best practices for orthopedic billing. Don’t worry! In this blog, we have outlined the key orthopedic billing and coding guidelines so you can easily perform all your billing procedures. 

Understanding Orthopedic Billing & Coding

Let’s first break down the difference between billing and coding. A lot of people use these terms interchangeably. However, they refer to entirely different services.

Orthopedic billing is submitting insurance claims for reimbursement of orthopedic medical services. The services can be provided by both large hospitals and small practices.

On the other hand, medical coding is the process that helps in making the final bill, which the billers will send to the insurance company later. It involves translating medical diagnoses, procedures, and treatments into standardized codes that insurance companies use for reimbursement.

If you want to complete the billing and coding process successfully, you must be well-versed in the following:

• CPT (Current Procedural Terminology) codes: used for medical, surgical, and diagnostic procedures.
• ICD-10 (International Classification of Diseases, 10th Revision) codes: are used to classify diseases, conditions, and injuries.
• Modifiers: provide additional information about a service or procedure without altering its meaning.

Essential CPT Codes for Orthopedic Billing

There are hundreds of codes used in orthopedic billing and a person can’t remember them all. However, every biller and coder must know the most commonly used codes.

Now, let’s first look at the coding series for different services, such as surgeries or laboratory services. After that, we will look at the most frequently used codes for specific procedures and diseases.

CPT Codes	Category & Description
Anesthesia (00100-01999 & 99100-99140)	Includes anesthesia-related services, such as pre-surgical evaluation, patient monitoring, and anesthesia administration during orthopedic procedures.
Surgical Procedures (10021-69990)	You can use this range to cover a range of orthopedic surgeries, from minor repairs to complex joint replacements.
Radiology (7010-79999)	Refers to imaging procedures like X-rays, MRIs, and CT scans used for diagnosing and tracking orthopedic conditions.
Pathology & Laboratory (80047-89398)	Represents lab tests and pathology services for analyzing tissue samples to aid diagnosis and treatment planning.
Medicine (90281-99299 & 99500-99607)	Encompasses miscellaneous medical services, including wound care, medication administration, and therapeutic injections.
Evaluation & Management (E/M) (99201-99499)	These codes are used for billing physician consultations. This can include patient assessments, diagnosis, and treatment planning based on complexity and time spent.

The ranges of codes in the above table will at least narrow down the code selection choice for you. As a healthcare provider, you must know that some procedures are more common than others. So, in the table below, we have listed the most frequently used CPT codes for orthopedic procedures:

Procedure	CPT Code
ACL Reconstruction	29888
Total Hip Replacement	27130
Total Knee Replacement	27447
Arthroscopy, Knee	29881
Carpal Tunnel Release	64721
Spinal Fusion	22633
Rotator Cuff Repair	29827
Fracture Repair	25600

Common ICD-10 Codes for Orthopedic Billing

ICD-10 codes are similar to CPT codes, but they are used to point out specific diseases rather than procedures or services. These codes are necessary to justify the procedure you performed for which you will be billing the patient. Following are the top 5 ICD-10 codes:

Condition	ICD-10 Code
Osteoarthritis of Knee	M17.10
Rotator Cuff Tear	M75.101
Fracture of Femur	S72.001A
Lumbar Disc Degeneration	M51.36
Carpal Tunnel Syndrome	G56.00

If you performed a procedure and used the correct CPT code in your billing, your claim may still face issues. If you fail to add the required ICD-10 code or use the wrong one to justify the procedure, the insurance provider may reject it.

The Importance of Modifiers in Orthopedic Billing

Modifiers are one of the most essential parts of any claim. Modifiers provide additional information about a medical service that you performed. Without proper use of modifiers, your claim will be denied.

Some of the most commonly used modifiers in orthopedic billing include:

Modifier	Description
-LT	Left side of the body
-RT	Right side of the body
-50	Bilateral procedure
-59	Distinct procedural service
-51	Multiple procedures in the same session
-76	Repeat the procedure by the same physician
-25	Significant, separately identifiable E/M service on the same day as another procedure

Best Practices for Orthopedic Billing & Coding

To improve your revenue cycle management, you should follow the orthopedic billing guidelines provided below:

Verify Insurance & Obtain Prior Authorization

To avoid any kind of claim denials, make sure to always verify the patient’s insurance before providing any services. A lot of the time, patients have expired insurance, or the procedure they require isn’t covered under their insurance plan. So, if you perform the procedure without verifying the details, the claim will get denied and you will suffer financial losses.

In addition to this, many orthopedic procedures, especially surgeries, require prior authorization from insurance payers. If you don’t get the approval before providing the services, your claim is likely to be denied.

Ensure Accurate Documentation

Apart from using the correct codes and modifiers, it is also essential to attach all the necessary and relevant documentation with your claim. The document not only supports the codes that you used but also supports the medical necessity of the procedure.

Physicians should document:

• Diagnosis and treatment plans
• Surgical details and post-operative care
• Relevant imaging results (X-rays, MRIs, CT scans)
• Time spent on evaluation and management (E/M) services

Follow Bundling & Unbundling Rules

A lot of the time there will be a situation where you will have to provide multiple medical services to a patient like surgery, anesthesia, laboratory sampling, etc. In this situation, many new billers and coders try to bill all of the related services separately, or sometimes they might try to bundle different services.

You might think this is okay, but in reality bundling and unbundling of procedures will almost always get your claim denied. Plus, frequent and deliberate use of these practices is a crime and can have some serious legal consequences.

Let’s look at an example where two services should be bundled together:

CPT code 29870 (diagnostic knee arthroscopy) is bundled with CPT code 29881 (knee meniscectomy) and should not be billed separately.

To avoid bundling mistakes, all billers and coders must remain updated on National Correct Coding Initiative (NCCI) edits.

Avoid Common Coding Errors

The most frequent billing mistakes include:

• Upcoding: Billing for a higher-level service than what was performed
• Downcoding: Using a lower-level code, leading to reduced reimbursement
• Incorrect modifier use: Misapplying modifiers, leading to claim denials
• Expired codes: Using outdated CPT or ICD-10 codes

Regular staff training and audits help eliminate these errors.

Claim Appeals & Denial Management

Do you know that 90% of denied claims are preventable, and appealing successfully can recover up to 60% of initially denied claims?

Denied claims are inevitable, but effective appeal management can recover lost revenue. Steps to streamline appeals include:

• Identifying the denial reason (missing documentation, incorrect codes, etc.)
• Correcting errors and resubmitting claims promptly
• Keeping records of denied claims for future reference

A simple way of reducing denials is to get orthopedic billing services from specialized billing vendors. These vendor companies are experts in billing methods, and their chance of making an error is much less than yours.

Wrapping Up

Orthopedic billing and coding require precision, compliance, and up-to-date knowledge of medical codes. If you follow the orthopedic billing guidelines in this blog, your claim rate and reimbursements will improve.

An easy way to boost your RCM is to outsource medical billing services to specialized billing companies. Investing in these companies ensures accuracy, compliance, and a healthier cash flow for your practice.