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Orthopedic Medical Billing

Orthopedic Medical Billing by Wise Medical Billing – Delaware, DE

A third of orthopedists medical billing report spending at least ten hours per week completing paperwork and administrative tasks, which contributes to burnout.

As a branch of medicine, orthopedic surgery or orthopedics treats conditions related to the Musculoskeletal System, which includes bones, joints, ligaments, tendons, and muscles.

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Complexities in Orthopedic Medical Billing

The field of orthopedic medical billing services encompasses a wide range of healthcare services and procedures. It is essential for orthopedic medical billers to have a solid understanding of coding, the billing process, and the insurance specific guidelines. As part of being proactive and receiving revenue as quickly as possible, the Orthopedic Billing/Coding Specialist is responsible for coding procedures and diagnosis codes and works closely with providers to obtain specific answers.

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Coding Issues:

Many doctors and internal teams struggle to keep up with the constantly changing medical coding guidelines, as well as payor guidelines. Providing regular education sessions is crucial for both professional coders and billers, as well as for providers.

Similar to other specialties, orthopedic billing codes are based on criteria established by the ICD-10-PCS. With these specific codes, medical billing specialists can bill the appropriate procedures to the patient’s insurance company, creating a more unified billing and coding process. When providing expert coding services, it is important to be familiar with standard CPT and ICD-CM diagnosis codes, as well as supply codes that adhere to CMS guidelines.

Procedures involving tendon and ligament injuries

The procedures involving the tendons and ligaments, such as a PLC reconstruction, are significantly different. Repair procedures for those parts, which typically requires submitting orthopedic surgery claims, would begin “0L” and “0M,” respectively. This includes:

  • The code for a tendon repair in the right lower arm could be coded as one of the following: 0LQ50ZZ, 0LQ53ZZ, or 0LQ54ZZ, depending on the approach being used.
  • The code for a ligament repair to the right lower arm could be coded as one of the following: 0MQ50ZZ, 0MQ53ZZ, or 0MQ54ZZ.
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Character Designation

For procedures, the character structure is as follows:
  • The first character designates the section in which the procedure falls in the ICD-10.
  • The second character denotes the body system that is being affected by the procedure.
  • The third character is determined by the root operation (main objective) of the procedure.
  • The fourth character is established as the character that specifies which body part is being affected by the procedure.
  • The fifth character defines the approach of the procedure.
  • The sixth character outlines the device being used.
  • The seventh character provides any other qualifying information pertinent to the procedure in order to make the coding process as simple as possible.

Account Receivable and Denials:

Growing deductibles and shortened filing timelines are putting a strain on orthopedic practices' accounts receivables (AR). For many orthopedic physicians, it is difficult to stay on top of AR and fight to win claims. The process of resolving medical claim denials often involves one or two attempts before the claim is written off. The impact of this on a practice's cash flow and revenue cycle is significant. Poor AR follow-up cost practices a great deal of money, disrupting the revenue cycle, which necessitates the establishment of a clear process for follow-up.

WMB Solution to Orthopedic Billing and Coding Issues:

Eligibility and Verification:

There are a number of medical reimbursement policies, so it is important to take proactive measures to verify insurance coverage, including if prior insurance authorizations are required. In the case of Medicare, if the orthopedic medical billing services are not covered, the patient must sign an Advanced Beneficiary Notice (ABN). The reimbursement policies of many leading commercial carriers, including United Health and the Blue Cross Group, can make processing medical bills more challenging. In light of this, it is imperative that medical billing companies take the time required to negotiate successfully with commercial carriers if necessary.

As part of our Orthopedic billing services, we handle patient scheduling, coding, and submitting claims. We also handle denials and rejections, compliance charting and coding, payer adjustments and paybacks, as well as bill collection. Due to our process effectiveness, clients tell us that our services increase their revenue so much that they do not consider them a cost.

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Utilization of the right technology:

With long surgical procedures and long follow-up schedules, it is essential that every patient encounter is accurately documented and billed. The ability to customize ortho-specific templates streamlines documentation by allowing the user to document from any web browser.
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Administrative efficiency:

Practice management software that is intuitive relieves you and your staff of administrative burdens. When you are evaluating your patients with the latest scoping technology, why do you use cumbersome, outdated software for managing appointments, storing patient profiles, and orthopedic billing?
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Expert Orthopedic Billing and Coding Team:

As medical billing guidelines continue to evolve under CMS/AMA/AAPC/ACA, our billing and coding professionals stay current to meet these challenges. Along with following up on unpaid or partially paid claims regularly, handling rejections, and appealing insurance denials in accordance with the billing guidelines, we pursue every dollar owed.
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Expert AR Management:

As a orthopedic medical billing company, we are proud of our ability to successfully pursue the difficult task of obtaining payment for old and aging claims for our clients. Our firm believes that every single dollar our clients provide is worth every single cent. By utilizing an aggressive AR management system and a professional AR team, we pursue those old and aging claims our clients have lost hope of collecting.
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Fast and Easy Access to Customer Support:

WMB recognizes the importance of prompt and easy communication between the billing company and the client. Our team of experienced and professional Customer Support representatives ensures that there is no lag in communication. You will be able to reach a dedicated Support representative by telephone, email, or text message at any time.

Our expertise in Orthopedics includes but is not limited to:

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Foot and Ankle Surgery
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Trauma Surgery
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Spine Surgery
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Pediatric Orthopedic Surgery
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Hip and Knee Surgery
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General Orthopedics
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Bone Health Center
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Sports Medicine
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Shoulder and Elbow Surgery
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Orthopedic Oncology
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Hand Surgery
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Osseo-integration Clinic

Our billing services for Orthopedic can increase your revenue and relieve you of the distractions and stress related to orthopedic medical billing services, so that you can concentrate on your patients.

You are under no obligation, so request a free AR analysis today!

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Injection & Pain Management

We provide compliant billing for foot injections, nerve blocks, and pain management procedures with accurate documentation and proper modifier usage.

Advanced Treatments

We handle advanced podiatric treatments with proper prior authorization management and comprehensive clinical documentation for high-value services.

Nail & Skin Procedures

We ensure accurate coding for nail debridement, callus removal, and skin lesion treatments with proper medical necessity justification and frequency compliance.

Surgical Procedures

We manage complex podiatric surgeries with accurate modifier usage, justified gaps between claims, and transparent timeframe documentation for all procedures.

Diabetic Care Management

We coordinate diabetic foot care services with proper medical necessity documentation and systematic condition correlation for comprehensive treatment.

Orthotic Services

We provide specialized billing for custom orthotics and devices, ensuring proper HCPCS and ICD-10 code pairing to justify fitting and delivery documentation.

Routine Care & Diagnostics

We handle routine foot care according to strict medical necessity criteria, ensuring precise paperwork and accurate coding for debridement and mycotic nail care, with proper frequency documentation.

Wound Care Partnerships

We provide accurate code coordination to prevent overlapping, ensure transparent tracking for pre- and post-surgical services, and deliver complete operative notes with reduced errors.

Graft & Skin Substitute Procedures

We select accurate application and graft codes based on location and wound size, audit surgical documents to ensure correct Q-code pairing for procedures and supplies, and assist in navigating state-specific Medicaid nuances through proactive prior authorization.

DME Billing

Robust compliance for orthotics, diabetic shoes, walking boots, and offloading devices. We ensure that certified coders are used for accurate coding and a perfect match for every claim. We evaluate the signature requirements of every payer and employ proactive strategies for expedited prior authorization.

Injection Therapies

We handle foot injection procedures with accurate MCO compliance, ensuring proper documentation and modifier usage for maximum reimbursement in the NY market.

Nail & Skin Care

We provide compliant billing for nail debridement and skin lesion procedures, meeting eMedNY-specific documentation requirements and ensuring proper medical necessity justification.

Advanced Treatments

We manage advanced podiatric treatments with NY-specific requirements, ensuring proper Q-code usage, comprehensive clinical packets, and expedited prior authorization processes.

Diabetic Care Management

We coordinate diabetic foot care services with wound care partnerships, ensuring proper documentation and transparent billing coordination for all involved providers.

Surgical Procedures

We handle complex podiatric surgeries with MCO coordination, ensuring accurate service sequencing and proper documentation to prevent overlapping claims and denials.

Orthotic Services

We provide specialized eMedNY-compliant orthotic billing with precise HCPCS coding, accurate ICD-10 pairing, and comprehensive modifier knowledge for maximum reimbursement.

Routine Care & Diagnostics

We ensure eMedNY compliance for routine foot care services with systematic condition documentation, proper modifier alignment, and comprehensive medical necessity justification for all procedures.

Graft & Skin Substitute Procedures

We prepare comprehensive clinical packages for fast approval, ensure thorough compensation for graft products and application, and prevent claims denials through accurate coding and correct submission.

Wound Care Partnerships

We provide accurate code coordination to prevent overlapping, ensure transparent tracking for pre- and post-surgical services, and deliver complete operative notes with reduced errors.

DME Billing

NY Medicaid’s top coverages include diabetic shoes and inserts, ankle-foot orthoses, braces, and custom-molded orthotics. We ensure eMedNY compliance through precise documentation, proper ICD-10 coding, and in-depth knowledge of modifiers to prevent denials.

Robotic Procedures

We deal with complex billing for radical prostatectomy, partial nephrectomy, and cystectomy by elaborative documents for the used devices. Our accurate codes and modifiers ensure successful approvals.

Telehealth

Our coders ensure accuracy for pre-op consultations, follow-ups, and LUTS/OAB management. Our optimized POS and use of modifiers have lower denial rates, as we demonstrate their necessity with clinical documents.

Urodynamics & Diagnostics:

We handle multi-channel involvement and billing complications with detailed CPT/ICD pairing. Our proactive prior authorization handling and expert claim structuring ensure error-free approvals.

Cystoscopy & Endoscopy:

We capture every detail and require evidence to ensure a smooth claim approval for office-based and hospital-based endoscopic procedures. We offer robust billing claims for biopsies and stone removals.

Lithotripsy (ESWL) & Stone Management:

We understand the complex bundling of ESWL, URS, and stone procedures, including device charges, anesthesia, and supplies for ongoing care. This in-depth knowledge ensures coding accuracy for each component.

Prostate Procedures & Biopsy:

We offer meticulous billing for targeted biopsies and imaging-guided prostate procedures, ensuring proper coordination of involved pathology and detailed capture of all allowable charges.

Implants & Prosthetics

We strictly follow the payer’s rules for high-value penile prostheses and testicular implants, ensuring proper coverage for device charges. Our coders ensure proper coding pairs, transparent vendor contracts, and logs for implants.

Pathology & Imaging

Our team possesses in-depth knowledge of the working principles of pathology and imaging centers. We collaborate with service providers to obtain accurate clinical information, ensuring that we capture all allowable charges.

Botox & Neuromodulation

For these complex services, we provide thorough coverage by handling prior authorization approvals and ensuring coding accuracy for both trial and permanent procedures. Our modifier’s accuracy provides high compliance with diverse payer requirements.

DME & Catheter Supplies:

We provide streamlined billing claims for catheter and drainage bag supplies, ensuring smooth and timely payment collections. Our proof-of-delivery and proactive SOPs save practices from financial loss.

DME & Catheters

We handle catheter supplies, ongoing maintenance claims, and billing for incontinence aids. We complete clinical documents with proof of need, supply evidence, and other supporting elements according to Medicaid requirements.

Pathology & Advanced Imaging

Outpatient labs and imaging services face facility-based billing cuts due to poor classification. We manage all complexities with professional splits and ensure compliant claims for radiology reads and pathology services.

Botox & Neuromodulation

We perfectly align the trial with a permanent implant and explain all stages with accurate codes. Our precise and error-free claim submission ensures maximum reimbursement for all elements.

Implants & Prosthetics

We offer support for commercial or Medicaid billing claims through transparent device tracking, fair vendor contracts, and compliant pre-auths, resulting in the successful implantation of penile prostheses, urinary sphincters, or slings.

Prostate Procedures & Biopsies

Pairing of biopsies with MRI-guided prostate means additional care for billing documents. These coordinated services required accurate pathology linking, ensuring that our robust component captures the necessary information.

Lithotripsy & Stone Procedures

We offer coding accuracy from ESWL to ureteroscopy by managing compliant documents for anesthesia, professional components, and prior authorization for such high-value services.

Cystoscopy & Endoscopic Interventions

Our technical expertise ensures billing accuracy for stent removals, cystoscopy, and facility-based endoscopy procedures. We separate each component of treatment to bring payment for all.

Urodynamics & Pelvic Testing

We justify the clinical necessity for urodynamic services. We offer hands-on support for authorization, ensure claims accuracy with diagnosis justifications, and document compliance for revisits.

Telehealth Evaluation Services

We have current information about eMedNY and MCO policies, ensuring coding accuracy with proper place-of-service designations, relevant modifiers, patient consent forms, and explanations of rendered services.

Robotic Procedures

We cover high-value procedures such as prostatectomy and nephrectomy, among others, by accurately documenting device costs in clinical documents and justifying their necessity under APG and facility-based insurance rules.

Pathology & Imaging Coordination

We resolve coding conflicts for these pairing services and ensure a justified coordination in documents to prepare a clean claim with reduced denial risks.

DME & Catheter Supply Managemen

The Medi-Cal and commercial payers have strict compliance requirements for DME. We streamline your claims with transparent usage tracking to ensure quality care and justified reimbursement.

Botox, Neuromodulation & OAB Treatments

We simplify the staged billing process for trials by managing prior authorization, the device’s paperwork, and submitting claims to accurate insurers to make it more manageable.

Implants & Prosthetics

We expedite your operation by handling authorization and vendor contracts, managing paperwork for pre-approvals, ensuring coordination, and maintaining inventory logs for stents and penile implants.

Prostate Procedures & Biopsies

Our experts accurately sequence the complex billing claims for MRI-fusion biopsies, prostate services, and imaging pairings across various payers to ensure maximum reimbursement for practices.

Lithotripsy & Stone Procedures

We navigate the complex process through accurate coding, transparent anesthesia reports, and the use of durable equipment, resulting in maximum coverage for every service.

Cystoscopy & Endoscopic Interventions

We capture each detail about scope procedures, stent placements, and biopsies performed in facility or ASC settings to prepare compliant claim documents.

Urodynamics & Pelvic Testing

We understand the unique compliance requirements, from bladder studies to pelvic floor testing, which prove the clinical necessity to ensure robust prior authorization and successful billing claims.

Telehealth Evaluation Services

California has broader telehealth services, with high Medi-Cal reimbursement for these services. We cover modality, consent, and explain facility settings so that you can get maximum advantage from every allowed charge.

Robotic Procedures

We precisely document robotic-assisted surgeries, negotiate with insurers, reflect the procedure’s complexity, and complete all paperwork in accordance with payer requirements to ensure a justified payment.

AB 72 – Surprise Billing Law

For podiatrists providing surgical services in out-of-network facilities, California’s AB 72 limits balance billing. Navigating this requires precise billing strategies.

Prior Authorization Hurdles


Increasingly, California payers require prior authorizations for DME, orthotics, skin grafts, and advanced wound care procedures. Failure leads to non-payment.

Workers’ Compensation Complications

California’s Workers’ Compensation system demands strict adherence to the Official Medical Fee Schedule (OMFS) and highly detailed documentation—especially for podiatric injury care, fracture management, and surgical interventions

Complex Wound Care & Skin Graft Billing

Podiatrists collaborating with wound care centers for diabetic ulcers, pressure sores, or limb salvage procedures face frequent denials related to skin substitute grafts (e.g., Apligraf®, Dermagraft®) and advanced wound treatments like NPWT (vacuum therapy).

Medi-Cal Restrictions

Medi-Cal limits podiatry services unless directly related to chronic disease management. Denials are common without proper coding and documentation.

Routine Foot Care Scrutiny

California insurers, including Medi-Cal and major HMOs (Kaiser, Blue Shield CA), often classify foot care (like nail debridement and callus removal) as non-covered unless medically justified by conditions like diabetes or peripheral vascular disease.