Policy / Article-013
Orthopedic Surgery Coding & Documentation Resource Sheet
- Effective Date: 01/01/2026
- Reviewed/Revised Date: 03/23/2026
- Next Review Date: 03/23/2027
- Origination Date: 01/01/2026
-
Originated Department:
Correct Coding Integrity
Audience
Providers treating orthopedic pathologies.
- American Medical Association CPT® 2026
- Centers for Medicare & Medicaid Services Medicare Claims Processing Manual
- NCCI Policy Manual
Clinical Providers
✓ Physicians
✓ Nurse Practitioners (NPs)
✓ PAs working in ED
Coding & Billing Professionals
✓ Compliance and audit personnel
✓ Medical Coders & CDI Specialists
Overview
Important —
Failure to comply with key points may result in claim denials, overpayments, or compliance violations.
All orthopedic surgical services must:
➔ Be medically necessary and supported by appropriate diagnoses
➔ Be fully documented in the operative record
➔ Be coded using accurate CPT, HCPCS (if applicable), and ICD-10-CM codes
➔ Follow CMS global surgery and NCCI bundling rules
➔ Include appropriate modifier usage when required
Documentation Essentials
Preoperative Documentation
✓ Preoperative Documentation
- Clear diagnosis (specific, laterality, acuity)
- Failed conservative treatment (if applicable)
- Imaging results (X-ray, MRI, CT)
- Medical necessity statement
Example:
Knee pain ➔ Right knee medial meniscus tear, chronic, failed PT and NSAIDs
✓ Operative Report Essential Must Include:
- Preoperative and postoperative diagnosis
- Procedure(s) performed
- Surgical approach (open, arthroscopic, percutaneous)
- Laterality (RT/LT)
- Findings
- Implants/devices used
- Complications
- Estimated blood loss
- Closure method
✓ Postoperative Documentation:
- Procedure outcome
- Condition of patient
- Follow-up care instructions
- Any complications
✓ Types of Treatment
- Closed Treatment (without manipulation)
- Closed Treatment (with manipulation)
- Open Treatment
✓ Documentation Must Include
- Fracture type (displaced, comminuted, etc.)
- Location (specific bone and site)
- Open vs closed
- Gustilo classification (for open fractures)
✓ Arthroscopy vs Open Procedures
- Do NOT code diagnostic arthroscopy separately if surgical arthroscopy is performed
- Arthroscopy is inclusive unless performed in a different compartment
✓ Bundling & NCCI Edits — Follow NCCI (National Correct Coding Initiative). Use modifier -59 or X modifiers only when appropriate
✓ Common Issue: Unbundling tendon repair + debridement (often included)
✓ Medical Necessity: Unbundling tendon repair + debridement (often included)
- Severity of condition
- Functional impairment
- Failed conservative treatment
Orthopedic Surgery Services
Includes pre-op visit (day before or same day), intraoperative services, and post-op care (0, 10, or 90 days)
Global Period
Description
000 Days
Minor Procedure
010 Days
Minor procedure + follow-up
090 Days
Major surgery
Global Surgical Package (CMS)
Important
Avoid denials by following documentation checklist precisely.
Modifier
Description & Examples
-RT / -LT
Laterality — e.g. Right knee arthroscopy
-50
Bilateral procedure — e.g. Both knees
-51
Multiple procedures — e.g. Multiple repairs
-59
Distinct procedural service — e.g. Separate anatomical site
-76
Repeat procedure — e.g. Same physician
-78
Return to — or — Complication
-79
Unrelated procedure (During global period)
-22
Increased complexity — e.g. Extensive scar tissue
Revision History
01/01/2026
Correct Coding Integrity
03/23/2026
Revised by Mountain Health CO-OP Policy Committee
Disclaimer
This document is for informational purposes only. It should not replace clinical judgment or provide medical advice. Coverage, benefits, and eligibility are determined by the member’s benefit plan. CPT codes and procedures included are for informational purposes only and do not guarantee reimbursement. © CPT Only – American Medical Association