- 410 Peachtree Pkwy, Suite 4245 Cumming, GA 30041
- Email: info@prohealthcareadvisors.com
- Services
Medical Billing and Practice Management
Creative Collection Solution
MD Audit Shield – RAC
Physician Credentialing
EMR/EHR Software
Electronic Fund Transfer (EFT)
CodeMAXX Services
Hippa
Orthopedic Medical Billing & Credentialing — Built for Surgeons, Sports Medicine & Spine Practices
Orthopedic medical billing is surgical billing at its most unforgiving — 90-day global periods that swallow E/M revenue without modifiers 24, 57, 58, 78 and 79, fracture-care packages that must be weighed against itemized coding case by case, same-compartment arthroscopy NCCI edits, and implant prior authorizations that stall six-figure cases.
Pro Health Care Advisors delivers end-to-end orthopedic medical billing and credentialing built for surgical groups, sports medicine clinics, spine centers, and orthopedic ASCs — focused on Global-Period Revenue Defense, Surgical Coding Accuracy, and Net Realized Revenue Growth.
Why Practices Trust Our Orthopedic Medical Billing Expertise
Generic billing vendors treat surgical claims like office visits with bigger numbers. They aren't. One knee injury can generate a trauma E/M, a fracture-care decision, a staged return to the OR, a post-op visit inside a 90-day global, and a brace with same-day DME rules — each with its own modifier logic. Our specialists work these exact scenarios daily, applying AAPC-certified coding standards to every claim that leaves your practice.
Global Surgical Package Mastery
Medicare's 10- and 90-day global periods bundle routine post-op care into the surgical fee — and quietly absorb every E/M you fail to modifier correctly.
We defend unrelated visits (24), decision-for-surgery evaluations (57), staged procedures (58), returns to the OR (78/79), and transfer-of-care splits (54/55) per the CMS global surgery rules — so the global period stops eating legitimate revenue.
Fracture Care Coding Decisions
Closed treatment with or without manipulation vs. itemized E/M-plus-casting is a financial decision as much as a coding one. We model both paths payer by payer — including 7th-character (A/D/S) and laterality accuracy that keeps trauma claims clean.
Arthroscopy & NCCI Edit Control
Same-compartment knee edits (29881/29880), shoulder scope bundling around 29827, and multiple-procedure reductions (51/59/XS) — sequenced and modifiered correctly before submission, not after denial.
Implant, Biologic & Imaging Prior Auth
Total joint site-of-service steering, ASC implant carve-outs, viscosupplementation and PRP criteria, and advanced imaging authorizations — managed on payer-specific timelines so six-figure cases never stall.
Workers' Comp & PI Lien Billing
State WC fee schedules, employer/carrier verification, letters of protection, and attorney lien aging — the revenue segment most orthopedic medical billing vendors quietly ignore, tracked here like any other payer.
Dedicated Orthopedic Account Team
A named Account Manager plus ortho-trained specialists — not a generic call center. A team that knows your case mix, your surgeons, and your payer contracts.
Orthopedic Medical Billing Across the Full Code Spectrum
From total joint replacement and arthroscopy families to fracture care, injections, and bracing — our AAPC-certified coders handle the complete musculoskeletal claim spectrum, with CodeMAXX coding review on every surgical claim.
9 Comprehensive Orthopedic Medical Billing & Credentialing Services
Standard vendors process claims. We engineer surgical revenue integrity. Groups searching for dependable orthopedic billing services get the complete stack in one engagement — global-period defense, fracture-care modeling, and lien tracking included as standard, not as add-ons.
Charge Capture & EHR Integration
Direct integration with your EHR and surgical scheduling systems through our EMR/EHR software service — operative notes to coded claims without manual re-entry errors.
Surgical Coding & Modifier Review
Certified coders validate CPT selection, global-period modifiers, laterality, and 7th-character accuracy. Our CodeMAXX service audits every surgical claim before submission.
Prior Auth for Implants, Biologics & Imaging
Total joint site-of-service enrollment, implant carve-out verification, viscosupplementation/PRP criteria, and MRI authorizations — tracked to payer-specific timelines from booking to OR date.
Claims Submission & NCCI Scrubbing
Ortho-specific scrubbing covers arthroscopy compartment edits, bilateral 50 rules per payer, multiple-procedure sequencing, and casting supply capture on every claim.
Denial Management & Medicare Appeals
We eliminate repeat denials — global bundling, medical necessity, unit conflicts — and file appeals through all five levels per the CMS Medicare appeals process.
Payment Posting & Variance Detection
Automated remittance processing with contracted-rate variance flagging — when a payer underpays a bilateral case or misapplies a multiple-procedure reduction, we catch it and dispute it formally.
Workers' Comp & PI Lien Management
WC fee-schedule billing, carrier verification, letter-of-protection tracking, and attorney lien follow-up with settlement-status monitoring — orthopedic medical billing revenue most vendors let age into oblivion.
Surgeon Credentialing & Enrollment
Our credentialing team manages CAQH, payer enrollment, facility privileges alignment (including robotic platforms), DMEPOS enrollment for bracing, and monthly OIG/SAM sweeps.
Orthopedic RCM Analytics & Reporting
Days in AR by payer class (including WC/PI), denial rate by procedure family, global-period E/M capture rate, and surgeon-level performance — part of our full medical billing and practice management platform.
Your Practice's Revenue Cycle Is Leaking. We'll Show You Where.
Most orthopedic groups lose 8–12% of potential revenue to global-period bundling, missed modifiers, and lien AR nobody works. Get a complimentary Orthopedic Payer Performance Audit — benchmarking your current orthopedic medical billing performance with zero obligation.
No sales pitch. No obligations. Just data.
Orthopedic Medical Billing for Every Practice Model
Each model bills differently — facility vs. professional components, 90-day globals vs. injection-clinic volume, commercial contracts vs. workers' comp fee schedules. We staff for all of them, with orthopedic medical billing workflows tuned to each model's case mix.
Private Orthopedic Surgery Groups
Full surgical lifecycle — decision-for-surgery E/M capture, 90-day global management, staged-procedure planning, and in-office ancillary billing (imaging with 26/TC, casting, DME) for multi-surgeon groups.
Orthopedic Surgery Centers (ASC)
Facility claims, implant carve-out invoicing, total-joint site-neutral enrollment, and per-case bundle reconciliation as commercial payers steer arthroplasty to the outpatient setting.
Sports Medicine Clinics
Arthroscopy families, biologic injection programs (viscosupplementation, PRP), ultrasound-guided procedures (20611), and multi-site location enrollment that prevents out-of-network flags for satellite offices.
Spine Practices
Fusion and decompression coding with instrumentation add-ons, co-surgeon and assistant modifiers (62/80/82/AS), and the multi-level documentation payers scrutinize hardest.
Hand & Upper Extremity Practices
High-volume fracture care decisions, digit-level laterality (FA–F9 modifiers), tendon repair globals, and same-visit splint application with supply capture.
Trauma & Workers' Comp-Heavy Practices
State WC fee schedules, employer/carrier verification, personal-injury lien tracking with settlement monitoring, and external-cause ICD-10 coding — keeping high-lien orthopedic medical billing operations solvent.
High-Impact Orthopedic Medical Billing Items We Manage Daily
These claim elements drive the majority of orthopedic medical billing revenue — and the majority of denials. Global math, modifier logic, and authorization timelines are where our team earns its keep.
| Claim Element | Category | Common Denial / Loss Trigger | Our Safeguard | Status |
|---|---|---|---|---|
| E/M inside 90-day global | Global period | Unrelated visits billed without modifier 24 | Global-calendar tracking per patient per procedure | ✓ Covered |
| Fracture care vs. itemized | Trauma coding | Wrong package choice — revenue left behind | Payer-by-payer financial modeling at charge entry | ✓ Covered |
| Bilateral modifier 50 | Payer rules | 150% vs. two-line rules vary by payer | Payer-specific bilateral logic in scrubbing | ✓ Covered |
| Arthroscopy NCCI edits | Same compartment | 29881 + 29880 compartment conflicts | Compartment-level edit review pre-submission | ✓ Covered |
| Viscosupp / PRP auth | Biologics | Criteria & unit documentation gaps | Payer criteria library + gold-carding enrollment | ✓ Covered |
| Same-day DME (L-codes) | Bracing | Orthosis billed without required documentation | Same-day DME rules engine + 855S enrollment | ✓ Covered |
| Robotic-assisted add-ons | Documentation | Platform utilization data missing from op note | Op-note templates meeting payer audit standards | ✓ Covered |
Getting Started with Orthopedic Medical Billing: Our 5-Step Onboarding
From your first free practice assessment through full revenue cycle management — onboarding takes less than two weeks.
Free Practice AR Assessment
We analyze your orthopedic medical billing performance, global-period E/M capture, denial patterns by procedure family, and WC/PI lien aging.
Credentialing & Privileges Audit
We verify CAQH profiles, payer enrollments, facility and robotic-platform privileges, and DMEPOS status — closing gaps before they delay surgical revenue.
EHR & Scheduling Integration
We connect to your platform — Epic, athenahealth, ModMed, Exscribe, and more — no migration required.
Active Billing & Compliance
Certified coders run claims from operative note to payment posting with continuous global, modifier, and authorization monitoring.
Monthly Practice Reporting
Real-time dashboards plus monthly optimization recommendations for your orthopedic medical billing performance.
Built-In RAC Audit Defense for Every Orthopedic Medical Billing Client
Surgical claims sit permanently on federal audit work plans — global-period E/M patterns and high-dollar arthroplasty cases draw targeted review. That is why MD Audit Shield is built into every engagement — audit prevention up front, full federal defense when it counts, at no extra charge.
Proactive — Not Reactive
Modifier logic, global calendars, and operative documentation are validated continuously — not reconstructed under audit pressure after an overpayment demand arrives.
AAPC-Certified Coding Accuracy
Certified coders validate every CPT selection, laterality assignment, and global-period modifier — eliminating the surgical patterns that put groups on RAC lists.
All 5 Medicare Appeal Levels
Redetermination to Federal District Court — we assemble surgery-specific documentation packets and argue every level of the CMS appeals ladder.
HIPAA-Compliant Workflows
Encrypted (AES-256) document handling with managed BAAs across billing and audit workflows keeps surgeon and patient data locked down.
Real-Time Compliance Reporting
Global-capture rates, audit risk indicators, open appeals, and compliance metrics stream into live dashboards your administrators can open any time.
Dedicated Audit Response Team
Your account gets one named specialist from the first day — never a rotating queue. When an auditor calls, you already know who picks up on your side.
Orthopedic Medical Billing — Frequently Asked Questions
With many commercial payers now steering total joint cases to the outpatient setting, your contracts and enrollment must be updated for site-neutral reimbursement — otherwise the higher-value facility component is left on the table.
Our orthopedic medical billing team manages site-of-service enrollment, ASC implant carve-outs, and per-case bundle reconciliation — so joint programs capture full value in either setting.
Payers increasingly require operative notes to capture the specific robotic platform utilization data behind robotic-assisted add-on reporting.
We build documentation templates that satisfy payer-specific medical-necessity audits — so robotic cases are paid, not pended for records.
Often yes. When the decision for surgery or definitive fracture management is made during the initial trauma evaluation, a separately payable E/M with modifier 57 (or 25 for minor procedures) is supported — but documentation must clearly reflect that decision, consistent with the CMS global surgery framework.
We also model when itemized E/M-plus-casting beats the fracture-care global package financially, payer by payer.
Largely, yes. Many payers now run real-time authorization portals and gold-carding programs that let high-compliance practices bypass standard review for biologic injections.
We manage payer-specific criteria, J-code selection (J7321–J7332), and unit documentation — so high-cost injectables are reimbursed at correct rates without treatment delays.
Every location needs correct site-of-service enrollment for every NPI — satellite therapy offices are the classic gap that triggers out-of-network denials.
Our credentialing team maintains location-level enrollment matrices, tracks remittance advisories, and files prompt-payment disputes when payers miss statutory windows.
Explore More Medical Billing & Credentialing Resources
Orthopedic medical billing is one of 30+ specialties we serve nationwide.
Physical Therapy Medical Billing & Credentialing
Post-surgical rehab is orthopedics' closest partner — therapy plan-of-care rules, 8-minute-rule units, and the referral chain from your OR to recovery.
Physical Therapy Billing →Podiatry Medical Billing & Credentialing
Foot and ankle care shares orthopedics' fracture globals, DME bracing rules, and surgical modifier logic — with its own payer quirks.
Podiatry Billing →Surgeon Credentialing Services
Full-lifecycle credentialing — CAQH management, facility and robotic privileges alignment, DMEPOS enrollment, and OIG/SAM exclusion monitoring.
Credentialing Services →30+ Medical Billing Specialties We Serve
From pathology and pharmacy to behavioral health and home healthcare — explore every specialty-specific billing program we offer.
View All Specialties →