What Are the Key CPT Codes Used in Orthopaedic Billing?

Billing and Coding in orthopaedics includes a wide range of services, including office visits, radiology and surgery on bone, joint and muscle. Since many different types of services can be billed for, it is crucial that the billing provider correctly assign the correct orthopaedic CPT code for each service so as to properly ensure the provider receives proper reimbursement for their services and complies with all Federal regulations. By assigning the correct CPT code for each procedure or service, the provider can minimise denied claims and audits and provide a steady stream of revenue from the services they perform.

The purpose of this article is to provide an overview of the top CPT codes for orthopaedic procedures, provide guidance on how codes are organised and illustrate best practices for orthopaedic billing and coding based upon current orthopaedic coding guidelines.

What are Orthopaedic CPT Codes?

Orthopaedic billing CPT codes are standardised procedure codes developed and maintained by the American Medical Association (AMA) to identify medical, diagnostic and surgical services that relate to the musculoskeletal system. In orthopaedic billing and coding, these codes clearly define the type of service that was performed, the method of performing the service and, in many cases, the degree of complexity involved.

Commonly used orthopaedic CPT codes include those relating to:

• Bone and Joint
• Muscle, Tendon and Ligament
• Spine and Extremities
• Fractures, Trauma and Degenerative Conditions

Proper utilisation of musculoskeletal CPT codes will result in timely payment and reduced processing time of claims.

Evaluation and Management (E/M) CPT Codes

The codes for E/M (Evaluation and Management) services provide the foundation of orthopaedic care. They cover the consultation with patients and visits to check the progress of treatment and to plan treatment. 

The common E/M orthopaedic CPT codes are:

• New Patient Office Visits = 99202-99205
• Established Patient Office Visits = 99212-99215

As per revised orthopaedic coding guidelines, an E/M code will be determined by the level of medical decision-making that occurred versus just the amount of time spent during the visit. To meet orthopaedic medical billing compliance, documentation must clearly demonstrate the diagnosis and treatment options and assess the risk level. 

What are the diagnostic imaging CPT codes in orthopaedics? 

Performing diagnostic imaging plays a very crucial role in knowing the reason for an orthopaedic injury and following the recovery process. Proper coding of diagnostic imaging services is also required to avoid claims being rejected.

Some examples of common orthopaedic procedure codes for diagnostic imaging are:

• Spine X-ray codes = 72020-72120
• Shoulder, arm, elbow, hip, femur and knee imaging codes = 73000-73080, 73500-73565
• CT and MRI codes for lower extremities = 73700-73723

Orthopaedic billing goes hand-in-hand with appropriately used CPT codes, and using the best possible diagnosis codes gets your claims accepted at a higher rate and helps support medical necessity. 

Fracture and Dislocation Treatment CPT Codes

Fracture injury treatment is one of the most frequent services provided in orthopaedic offices Accordingly, the CPT codes for orthopaedic procedures related to fractures rely on whether the treatment was manipulative, operative, or follow-up care after a manipulation or an operative procedure.

Examples of CPT codes for orthopaedic procedures associated with fractures are:

• Clavicle and shoulder fracture codes = 23500-23680
• Humerus and Elbow Fracture and/or Manipulation Codes = 24500-24685 
• Femur Fractures and/or Manipulation Codes = 27500-27514 

You will have to verify if manipulation was performed when using these CPT codes for billing your orthopaedic patients, as this may affect your reimbursement.

Orthopaedic Billing Services for Injections

CPT codes for injection into joints are commonly used for pain management and inflammatory conditions such as arthritis.

Orthopaedic CPT codes for injection include:

• 20600: Small joint injection/aspiration
• 20605: Intermediate joint injection/aspiration
• 20610: Major joint injection/aspiration (knee, shoulder, hip)

When an orthopaedic coder performs one of these services, they should provide sufficient documentation on the patient’s service and use the correct modifier(s).

Orthopaedic Coding Services for Surgery

Surgery generates much of an orthopaedic practice’s revenue; therefore, it is important to accurately code each procedure. Many orthopaedic surgery procedures contain what is known as a “global period”, which includes three phases of care prior to, during and after surgery.

Below are some common orthopaedic surgery CPT codes.

• Arthroscopic Rotator Cuff Repair (29827) 
• Total Hip Replacement (27130)
• 27447: Total knee replacement
• 63030: Lumbar discectomy

Orthopaedic coding practices and policies regarding “surgical packages” are critical in preventing the unbundling of billed services from a single procedure and also in identifying all billable services.

Orthopaedic Spine and Musculoskeletal CPT Codes 

Spine-related treatments can be complex and require detail in documentation; therefore, there are challenges specific to spine CPT coding.

Musculoskeletal CPT codes include:

• 22551-22899: Spinal fusion CPT codes
• 62320-62327: Epidural/spinal injection CPT codes
• 64479-64484: Nerve block injection CPT codes

Appropriately identifying and reporting CPT codes for orthopaedic procedures will enhance compliance and reduce the risk of payer-audited claims. 

Best Practices in Orthopaedic Billing and Coding 

To help ensure compliance, orthopaedic practices should take the following steps: 

• Keep updated with annual CPT code-relevant changes. 
• Adhere to payer-specific orthopaedic coding guidelines.
• Document all clinical details to support services billed.
• Correctly use modifiers to avoid claim denial.
• Regular internal audits to identify gaps in coding.

Orthopaedic medical billing is only as efficient as the documentation process used.

Conclusion

Proper orthopaedic CPT codes provide the foundation for efficient and compliant medical billing in an orthopaedic practice. Whether it be an E/M visit or imaging, whether it be fracturing care or complex surgery, using the proper orthopaedic billing CPT codes ensures timely payment and compliance with regulations. Understanding common orthopaedic procedure codes and following established orthopaedic coding guidelines and being knowledgeable about musculoskeletal CPT codes, orthopaedic practices can greatly increase their billing efficiency and profitability.

A well-established process for orthopaedic billing and coding will assist in reducing claim denials and allow providers to spend more time doing what is important – caring for patients.

FAQs 

When should CPT codes be reviewed for updates?

Because the AMA updates CPT codes every year, it follows that new codes will be generated, certain codes will be eliminated – and most of the codes currently in use will require revision. That means at least once per year you need to do the work to review your CPT codes. 

Why do orthopaedic medical billing claims have the largest portion of denied claims?

To provide the best possible defence of your billing for orthopaedic services, you will require clear clinical notes, imaging reports, operative summaries, and treatment plans to establish justification for the services you are billing and to demonstrate why they were medically necessary.

Do modifiers get used in orthopaedic medical billing?

Yes. There are many frequently used modifiers indicating a separate service was performed: separate and distinct service (-25), the correct side (laterality) of the body was treated (-LT/-RT), and that a service can be billed separately from other services that can be included in separate claims (-59). 

What is the required supporting documentation for orthopaedic billing? 

The three most frequent reasons for denied claims 

(1) Lack or insufficiency of documentation

(2) Improper selection of code

(3) Missing Modifiers

(4) Mismatch of diagnosis with procedure code(s).

How do I handle Global Periods for my Orthopedic Surgeries?

Global periods typically cover both Pre-Operative and Post-Operative Care for most orthopaedic procedures. Any services provided during the time of the global period will require meeting specific payer requirements to be billed separately.