Let’s face it. Orthopedic billing is complicated. With constantly changing CPT codes, modifier rules, and insurance quirks, it’s easy to get bogged down by avoiding mistakes. We often forget the main goal: getting paid fully and fairly.
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You’re Probably Leaving Money on the Table. Here’s How to Fix It
This guide is here to help you do just that. Whether you’re a biller, coder, or practice manager, you’ll walk away with real-world tips, a cheat sheet you can use daily, and insider advice you won’t find in most generic blogs.
The Hidden Revenue Gaps No One Talks About
1. We Get Comfortable with the Same Codes
Let’s be honest, we all have go-to codes. But sticking to them blindly (hello, 29881) can mean missing add-ons like G0289 that pay well and are often justified. It’s not about overcoding, it’s about billing what you actually did.
2. Modifiers Can Make or Break a Claim
Did you know that one wrong modifier can get your entire claim denied? Yep. Especially when it comes to 59 and its cousin modifiers (XU, XS, etc.). Knowing when and how to use them is key.
3. Your EHR Isn’t Smarter Than You Think
Many systems are designed to be safe, not effective. If your EMR isn’t reminding you about surgical navigation or omitting fracture care codes, it’s costing you money without you even noticing.
Commonly Missed CPT Codes That Deserve a Second Look
These aren’t just codes, they’re missed opportunities:
- 29826 Subacromial decompression. Too often bundled incorrectly.
- G0289 Another knee compartment? That’s billable under the right conditions.
- 20985 Navigation tech in spine and joint surgeries. Easy to miss, easy to justify.
- 22513 to 22515 Vertebroplasty codes. Just make sure your documentation is on point.
- 99291 to 99292 Critical care during acute trauma cases. Often overlooked.(AAOS)
How AI Can Help You Spot Missed Revenue (and What Not to Trust It With)
What AI can do well:
- Suggest modifiers based on patterns
- Flag CPTs based on op note keywords
- Highlight unbilled procedures that are likely needed
What it can’t replace:
- Your judgment as a coder
- Clinical nuance in op notes
- Complex billing scenarios involving multiple surgeons or global periods
CPT and Modifier Cheat Sheet for Orthopedic Billing in 2025
| Procedure Type | Underused CPT | Modifier Combo | When to Apply | Common Denial Reason |
| Shoulder Arthroscopy | 29826 and 29827 | 59, LT | If decompression done separately from cuff repair | Modifier sequencing |
| Knee Arthroscopy | 29881 and G0289 | 59, RT | Second compartment addressed, different pathology | Bundling edits |
| Fracture Care | 25600 | 54 and 55 | Shared care across providers or facilities | Missing or wrong modifiers |
| Spine Fusion | 22633 and 22853 | 22 | Complex instrumentation or technique | No op note justification |
| Surgical Navigation | 20985 | None | If navigation tech used during procedure | Lack of documentation |
Print it. Bookmark it. Share it with your team.
Help Your Surgeons Help You: Better Notes Mean Better Billing
Surgeons aren’t coders. But the way they document makes or breaks your claims. For Ortho Coders and other medical billing specialists, accurate documentation is key. Encourage phrases like:
“Performed subacromial decompression in addition to rotator cuff repair, addressing a distinct pathology.” “Both compartments were visualized and treated during the knee arthroscopy.”
It doesn’t have to be perfect, just clear enough to justify the code. This clarity is vital for efficient healthcare billing services.
Workflows That Actually Make a Difference
For practices thinking about Professional Medical Billing Solutions for Physicians, improved workflows are essential.
- Scrub cases within 48 hours to catch missing CPTs while details are fresh.
- Do a monthly audit of op notes versus claims submitted.
- Track RVUs per provider to spot patterns and gaps.
Even one of these steps can reveal thousands in missed revenue. This highlights the need for solid internal processes or the use of third-party medical billing companies.
Real Example: How One Ortho Practice Unlocked More Than 100K
One of our CHB clients, a midsize ortho group, was doing everything correctly. Many practices decide to hire specialists like us for their medical billing for this reason.
But after reviewing 90 days of post-op billing:
- They were missing G0289 in over half of knee scopes.
- Modifiers were wrong or missing in 20 percent of spine fusion claims.
- Navigation CPTs weren’t even on the charge master.
We helped them fix the workflow, retrain staff, and add CPT triggers. This approach, which third-party medical billing companies often provide, along with specialized credentialing services if necessary, resulted in over 100K dollars in extra payments.
Final Thoughts: Codes Aren’t Just for Billing, They’re Tools for Growth
Every CPT tells a story. Is your story complete? Or are you letting revenue slip through the cracks? Professional Medical Billing Solutions for Physicians ensure your story is not just complete, but optimized.
In 2025, your best bet isn’t working harder, it’s working smarter. Use this guide to challenge old habits, fix blind spots, and boost your revenue without seeing more patients.
Need Help?
Book your free consultation with CHB today. Our billing experts will guide you through your current process, find chances for improvement, and demonstrate how to recover missed revenue quickly and correctly. We are your reliable source for healthcare billing services.
Let’s make your billing smarter, not harder.
Why are my orthopedic claims frequently denied, even with seemingly correct coding?
Incorrect modifiers, insufficient documentation, NCCI bundling issues, missing pre-auths, and vague diagnoses are common culprits.
How can I effectively appeal a denied orthopedic claim?
Understand the denial, gather strong supporting documentation, draft a clear appeal, and submit it on time.
