Major orthopedic procedures carry a 90-day global period: the surgery, its typical follow-up, and routine post-op care are one payment. Revenue leaks when practices bill routine post-op visits inside the global (they deny), miss the modifier 24 exceptions for unrelated problems, or fail to bill eligible hardware separately under the terms of their payer contracts.
Global surgical periods — 0, 10 or 90 days depending on the procedure — are defined by CMS and mirrored by most commercial payers. A total knee arthroplasty (27447) or lumbar fusion (22612) includes 90 days of routine follow-up. The trap is the word routine: a visit for a new, unrelated problem inside the window can be billed with modifier 24, but only with a distinct diagnosis and documentation that survives audit.
Hardware is the second frontier. Whether a practice can separately bill implants (or must bundle them into the procedure payment) depends on the payer contract — Medicare generally includes routine implants in the surgical payment, while some commercial and workers' compensation contracts carve them out. Our charge-capture rules are configured per contract, so eligible implants are billed with the correct code and documentation every time.
Third, sequencing. When a surgeon performs multiple procedures in one session, secondary procedures are subject to multiple procedure reduction — typically paid at 50% — and the order of codes on the claim determines the reimbursement math. Modifiers -51, -59 (or the X{E,P,S,U} family) and -XS must reflect what actually happened in the room. Generic modifier defaults are one of the most expensive habits in orthopedic billing.
“48% of leaders named denials and appeals their practice’s largest source of revenue leakage, compared with 23% who cited front-end issues.”