Orthopaedic Surgery Billing & Coding Guide
Global surgery package, modifier 24/57/58/78/79, fracture care vs E/M billing rules.
Common Orthopaedic Surgery CPT Codes
Ranked by claim frequency, with current MPFS work RVUs and global periods.
| Code | Description | Work RVU | Total RVU | Global |
|---|---|---|---|---|
| 27447 | Total knee arthroplasty | 19.11 | 34.71 | 090 |
| 27446 | Revision of knee joint | 16.70 | 31.36 | 090 |
| 27130 | Total hip arthroplasty | 19.11 | 34.79 | 090 |
| 29881 | Arthrs kne srg mnisectmy m/l | 6.85 | 15.44 | 090 |
| 29880 | Arthrs kne srg mnisectmy m&l | 7.21 | 15.96 | 090 |
| 29882 | Arthrs kne srg mnisc rpr m/l | 9.36 | 19.22 | 090 |
| 29883 | Arthrs kne srg mnisc rpr m&l | 11.48 | 23.53 | 090 |
| 29827 | Sho arthrs srg rt8tr cuf rpr | 15.20 | 29.23 | 090 |
| 29823 | Sho arthrs srg xtnsv dbrdmt | 7.78 | 16.73 | 090 |
| 29824 | Sho arthrs srg dstl claviclc | 8.76 | 19.13 | 090 |
| 29826 | Sho arthrs srg decompression | 2.93 | 4.42 | ZZZ |
| 20610 | Drain/inj joint/bursa w/o us | 0.77 | 2.06 | 000 |
| 20611 | Drain/inj joint/bursa w/us | 1.07 | 3.12 | 000 |
| 20680 | Removal of implant deep | 5.81 | 18.92 | 090 |
| 20670 | Removal implant superficial | 1.75 | 11.09 | 010 |
| 27236 | Treat thigh fracture | 17.17 | 32.63 | 090 |
| 27244 | Treat thigh fracture | 17.73 | 33.57 | 090 |
| 27245 | Treat thigh fracture | 17.73 | 33.48 | 090 |
| 23412 | Repair rotator cuff chronic | 11.63 | 23.70 | 090 |
| 23430 | Repair biceps tendon | 9.92 | 20.85 | 090 |
What Orthopaedic Surgery practices are leaving on the table
High-value services that consistently get under-billed across the specialty. Each one is rooted in current 2026 fee schedule and policy updates.
Arthroscopy add-on codes: 15-30% of practices miss add-on billing. If performing meniscectomy + synovectomy + chondroplasty in different compartments, each gets its own code.
Ultrasound-guided injections (76942): Adds $40-60 per injection. Most payers cover it. Document: 'Ultrasound guidance used for needle placement with real-time visualization.'
Global period follow-up: Most follow-up visits during the 90-day global period are included. But unrelated problems are separately billable with modifier 24.
DME prescriptions: Post-surgical braces, orthotics, and bone stimulators generate ancillary revenue. Bill HCPCS codes (L-codes for orthotics, E-codes for DME).
Fracture care global: Fracture management includes initial treatment + expected follow-up. But additional procedures (re-reduction, delayed fixation) are separately billable.
Multi-level spine: Each additional level of decompression or fusion is an add-on code. A 2-level fusion = base code + add-on. 3-level = base + 2 add-ons. Significant revenue per additional level.
Code pairs that auto-bundle to CO-97
From the National Correct Coding Initiative for Orthopaedic Surgery. The rationale tells you when a modifier legitimately bypasses the edit and when it cannot.
Meniscectomy (29881) bundles with chondroplasty (29880). If both performed, bill 29881 only — 29880 is included. Modifier 59 WILL unbundle but requires separate compartment documentation.
Meniscectomy (29881) includes diagnostic arthroscopy (29875). Never bill both. The diagnostic scope is always included in the therapeutic procedure.
Meniscus repair medial (29882) bundles with lateral (29883). If repairing both compartments, bill 29882 + 29883-59 with documentation of separate compartments.
Total knee (27447) includes any arthroscopic procedure. Do NOT bill arthroscopy codes with total knee replacement.
Large joint injection (20610) bundles with intermediate (20611) on same date. Bill per joint, not per injection.
Open rotator cuff repair (23412) bundles with arthroscopic (29827). Bill one approach, not both.
Modifier Guidance for Orthopaedic Surgery
When each modifier legitimately applies in this specialty, with denial-pattern context and audit-defense documentation.
REQUIRED on all lateralized procedures — knee arthroscopy, joint injections, shoulder surgery. Forgetting laterality = automatic denial.
Use for multi-compartment arthroscopy when separate compartments are documented. XS (separate structure) is preferred over 59.
Bilateral modifier for same-day bilateral procedures. Payment = 150% of unilateral rate. Example: bilateral knee injections (20610-50).
Return to OR during the post-op global period for a complication. Does NOT restart the global period. Only the work RVU is paid.
Unrelated procedure during global period. DOES restart the global period. Must be truly unrelated to the original surgery.
Staged procedure during global period. Planned return to OR (e.g., hardware removal after fracture healing). Does NOT restart global period.
Documentation requirements
What needs to live in the encounter note for these codes to survive a payer audit.
- Joint replacement: Document failed conservative treatment (PT, injections, medications, duration), radiographic evidence (joint space narrowing, bone-on-bone), functional limitation, and BMI.
- Arthroscopy: Document specific compartment(s) entered and treated, method of treatment (debridement vs repair vs excision), pre-op MRI findings, and intra-operative findings.
- Fracture care: Document fracture type (open/closed, displaced/non-displaced), reduction method, fixation type, and post-reduction imaging.
- Joint injection: Document joint name, laterality, indication (specific diagnosis), medication injected (name, dose, volume), and technique (ultrasound-guided = add 76942).
- Spine procedures: Document level(s), approach, specific decompression/fusion performed, instrumentation used, and fluoroscopy time.
OIG and audit triggers in Orthopaedic Surgery
Patterns that show up in OIG Work Plans, RAC audits, and CERT improper payment reviews. Build internal compliance checks around these.
Arthroscopy + diagnostic scope: 29875 (diagnostic) is ALWAYS included in the therapeutic procedure. Never bill it separately. This is the #1 ortho billing error.
Laterality missing: LT/RT is required on every bilateral procedure. Payers automatically deny without laterality. Some ERAs don't show the denial reason — it just gets reduced to zero.
Global period confusion: 27447 (total knee) has a 90-day global. All routine follow-up is included. A new fracture during global period IS separately billable with modifier 79.
Hardware removal timing: 20680 is separately billable only after the global period ends. During global = included. Exception: if removal is due to infection (complication), use modifier 78.
Joint injection frequency: Some payers limit injections to 3-4 per joint per year. Exceeding this = denial for medical necessity. Track injection frequency per patient per joint.
MRI not done before arthroscopy: Most MACs and commercial payers require MRI before elective arthroscopy. Without it, the surgery gets denied retroactively.
Payer-specific billing notes
Where the major payers diverge from generic Medicare rules in Orthopaedic Surgery.
ME Medicare +
LCD policies require: failed conservative treatment (6+ weeks), MRI before arthroscopy (most MACs), BMI restrictions for joint replacement (varies by MAC). Global period: 90 days for major surgery, 10 days for minor.
UN UnitedHealthcare +
Prior auth required for ALL surgeries. Requires 12 weeks of conservative treatment for joint replacement. Strict on BMI (may deny >40). Gold card program exempt some surgeons.
AE Aetna +
Pre-cert required. Uses InterQual criteria. Requires prior imaging and conservative treatment documentation. Appeal rate for ortho denials is higher than average.
BC BCBS +
Varies by state. Some plans require second surgical opinion for joint replacement. Most require 6-12 weeks conservative treatment. Auth timelines vary 3-14 days.
WO Workers Comp +
Different rules entirely — state-specific fee schedules, case management required, utilization review for every procedure. Treatment guidelines vary by state.
Standard Orthopaedic Surgery coding workflow
1. Identify all procedures performed (list every compartment, every level, every joint). 2. Select base code for the primary procedure. 3. Add add-on codes for additional compartments/levels. 4. Apply laterality modifiers (LT/RT). 5. Apply modifier 59/XS for separate compartments. 6. Check NCCI edits for all code pairs. 7. Verify auth was obtained. 8. Match ICD-10 to each procedure — traumatic vs degenerative determines code selection. 9. Document global period for post-op tracking.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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