Orthopedic Surgery & Sports Medicine Billing Audit
Protect your high-value surgical reimbursements, overturn unbundling denials across 90-day global periods, and recapture missing fluoroscopic guidance revenue.
Orthopedic surgery practices experience severe revenue loss due to payer misinterpretation of 10-day and 90-day global surgical periods, improper denials of ultrasound-guided joint injections (CPT 20610 / 20611), and missing implant pass-through fees. Commercial payers frequently disregard Modifier 58 (staged procedure), Modifier 78 (unplanned return to OR), and Modifier 79 (unrelated procedure during postoperative period). Our surgical coding reviewers conduct comprehensive operative report reviews to ensure every screw, pin, graft, and distinct procedural service is fully compensated.
Audit red flags
- Joint injections (CPT 20610) performed in-office routinely bundled into initial evaluation visits.
- Ultrasound guidance billed without meeting ACR documentation standards (permanent image stored in PACS).
- Complications treated during the 90-day global surgical period left unbilled without Modifier 78.
- Implant invoices missing from clearinghouse claim packets leading to silent 0% reimbursement on surgical hardware.
Audit action plan
- 1. Operative Dictation Scrub — Audit a sample of 50 operative notes against surgical CPT codes to confirm all bone grafts, hardware removal, and neuro-monitoring codes were captured.
- 2. Global Period Collision Audit — Cross-reference postoperative E/M visits against surgical dates to identify billable complications and unrelated anatomical complaints (Modifier 79).
- 3. Implant Pass-Through Reconciliation — Match vendor purchase invoices against carrier remittance lines to recover unpaid orthopedic hardware reimbursements.
Codes reviewed
- 20610 / 20611 — Arthrocentesis / Joint Aspiration / Major Injection (with Ultrasound)
- 27447 — Total Knee Arthroplasty (TKA)
- 29881 — Arthroscopy, Knee, Surgical with Meniscectomy
- 22612 — Arthrodesis, Posterior or Posterolateral Technique (Lumbar Spine)
Frequently asked questions
Can an orthopedic surgeon bill for an office visit during a 90-day global period?
Yes. If the patient is evaluated for a new, unrelated injury or a different joint, the visit is fully billable with Modifier 24 (Unrelated E/M during global period), provided the note explicitly documents the distinct diagnosis.
How does your audit handle assistant surgeon (Modifier 80) rejections?
We audit the operative note for specific documentation verifying why the procedure warranted dual surgeons, matching against payer-approved surgical lists to overturn denials.