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Orthopedic Medical Billing: Global Periods & Modifiers

By Dynamic Medical Billing Solutions · Updated October 13, 2026 · 6 min read

Orthopedic billing is built around the global surgical package: payment for a procedure includes the surgery and a defined period of related care. Get the global period or the modifiers wrong and you either lose revenue or bill for visits that should be included. This guide covers the rules orthopedic practices need to get right.

The Global Surgical Package

Each surgical CPT code has a global period of 0, 10 or 90 days, set in the Medicare Physician Fee Schedule and followed by many other payers. The package generally includes the preoperative visit (typically the day before or day of major surgery), the procedure itself, routine postoperative care by the surgeon and related complications that do not require a return to the operating room.

Global period	Typical examples	Notes
0 days	Many minor procedures, such as joint injections and endoscopies	Includes the procedure and the same-day care. Later visits may be billable.
10 days	Many minor surgical procedures and some fracture care	Related visits in the next 10 days are included.
90 days	Major surgery such as joint replacement, ACL reconstruction and fracture surgery	Related post-op visits for 90 days are included, plus the pre-op visit in the day before or the day of surgery.

Always check the global period for the specific code in the current fee schedule, since the period is code-specific and some payers differ.

Modifiers That Protect Orthopedic Revenue

• 24 — an unrelated E/M by the same physician during a postoperative period (for example, a visit for an unrelated problem).
• 25 — a significant, separately identifiable E/M on the day of a minor procedure.
• 57 — an E/M that results in the decision to perform major surgery. This is how the visit where the surgery decision was made can be billed when it falls in the day before or the day of surgery.
• 58 — a staged or related procedure by the same physician during the postoperative period.
• 78 — an unplanned return to the operating room for a related complication.
• 79 — an unrelated procedure by the same physician during the postoperative period.
• 50, RT, LT — bilateral procedures and laterality. Laterality errors are a classic orthopedic denial.
• 51 — multiple procedures in the same session, which are reduced under multiple-procedure rules.
• 62, 80, 82 — co-surgeons and assistant surgeons, which many payers restrict to specific procedure codes.

Missing modifier 57 is a common source of lost revenue. The decision-for-surgery visit is not part of the global package when it is billed with 57, while the same visit billed without it is bundled.

Fracture Care and Casting

Fracture care codes (such as 25600 and many others in the 2xxxx range) include the initial casting or splinting and follow-up care during the global period. Because of that, the application of the first cast is generally not billed separately for the same fracture. Casting supplies can sometimes be billed separately in the office with Q codes (Q4001–Q4051), depending on payer rules. Cast changes during the global period have their own rules, so check each payer's policy. Check payer-specific policy and document fracture type, whether open or closed, whether manipulation was performed and the site and laterality.

Injections and Joint Procedures

• Joint and bursa injections are reported with codes such as 20610 and 20611 (the latter with ultrasound guidance and permanent recording). Laterality and each joint should be documented.
• The drug is billed separately with the appropriate J-code and units.
• Viscosupplementation (hyaluronic acid) usually requires prior authorization and a documented trial of conservative therapy.
• Ultrasound guidance requires a saved image and report if billed.
• Same-day E/M with an injection requires modifier 25 and a distinct, documented evaluation.

Durable Medical Equipment and Implants

Many practices supply braces, walking boots, slings and crutches in the office. These are billed with HCPCS L, E and A codes and require the practice to be enrolled as a DMEPOS supplier with the appropriate payers, with proof of delivery and patient signature. For surgery, implants and hardware are usually billed by the facility; confirm who bills and under which contract if the practice owns an ambulatory surgery center.

Workers' Compensation and Auto Accident Claims

Orthopedic practices see a large share of injury-related claims. These involve claim numbers, adjusters, authorizations for each visit or treatment plan, state-specific fee schedules and forms such as the CMS-1500 with the injury date and employer. They are often slower to pay and have different appeal and timely-filing rules from standard health insurance. Verify liability coverage at scheduling, record claim numbers and adjuster contact details and track these accounts separately in A/R. Our guide on reducing days in A/R applies here with extra force.

Common Orthopedic Denials and Prevention

• Post-op visits billed inside the global period — build a global-period tracker in the PM system.
• Missing modifier 57 on the decision-for-surgery visit.
• Laterality and bilateral errors (RT, LT, 50).
• Prior authorization missing for surgery, MRI or therapy (CO-197).
• Assistant surgeon or co-surgeon not allowed for the code and payer.
• Medical necessity for injections or imaging without documented conservative treatment.
• Unbundled procedures due to NCCI edits.

Because global periods and modifiers are a compliance area, a periodic compliance review is worthwhile. Our physicians' billing services and denial management teams work with orthopedic practices on these workflows.

This article is educational and not a substitute for current CPT, CMS or payer policy.

Tracking Global Periods and Surgical Scheduling

The best defense against global-period errors is a system that knows them. Set up your practice management software, or a simple tracker if it cannot, to record the date of surgery, the CPT code, the global period and the end date for each surgical patient. When a visit is scheduled, the front desk and biller should see immediately whether it falls inside a global period and whether it is related. Related post-operative visits should be recorded as no-charge or with the proper post-op code for tracking, and unrelated visits should be billed with the correct modifier and a diagnosis that shows they are unrelated.

Also coordinate with the surgery scheduler: authorizations should list every planned CPT code, laterality, assistant surgeon and facility, because a change to any one of them can invalidate the approval. A short pre-surgery checklist covering eligibility, authorization, implant and equipment needs and the financial conversation with the patient prevents a surprising number of denials.

Frequently Asked Questions

What is a global period in orthopedic billing?

A global period is the number of days after a procedure (0, 10 or 90) during which routine related care by the surgeon is included in the surgery payment. It varies by procedure and is set in the fee schedule, so check each code.

When should I use modifier 57?

When an E/M visit results in the decision to perform major surgery and takes place on the day before or the day of the procedure. Without modifier 57, that visit is bundled into the global package.

Can I bill separately for casting supplies?

Often yes in the office, using Q codes, depending on payer rules. The cast application for a fracture treated under a fracture care code is generally included. Check payer policy and document what was done.

Why are orthopedic injection claims denied?

Common reasons are missing laterality, no documented conservative treatment, a missing prior authorization for viscosupplementation, or an E/M billed without modifier 25 on the same day.

How are workers' compensation claims different?

They use claim numbers and adjusters, often require authorization for visits or treatment plans, follow state fee schedules and usually have different timely filing and appeal rules. Track them separately in A/R.