Orthopedics revenue cycle management
Surgery-heavy and DME-heavy, orthopedics needs tight prior auth and global-period discipline - the biggest sources of lost revenue. AI agents assemble PAs, keep modifiers and globals straight, and run the full cycle.
Orthopedics combines surgery, advanced imaging, injections and durable medical equipment - each with its own authorization and coding rules. AI agents assemble PAs, track global periods, get surgical modifiers and DME HCPCS right, and work claims, posting, denials and collections.
Prior authorization
- MRI, injection, surgery & DME PA - Assembles authorizations for imaging, injections, surgery and durable medical equipment (braces).
- PA status & expiry tracking - Polls status and tracks expiry.
- Conservative-therapy documentation - Assembles the conservative-treatment history payers require before surgery.
- Peer-to-peer scheduling - Books and preps peer-to-peer reviews when a PA is challenged.
Coding & compliance
- Surgical coding & global periods - Codes procedures and tracks 10/90-day global periods.
- Modifier accuracy - Validates modifiers 24, 25, 58, 78 and 79.
- DME HCPCS coding - Codes braces and equipment with the correct HCPCS and modifiers.
- Bundling & assistant-surgeon check - Checks NCCI bundling and assistant-surgeon eligibility.
Eligibility & benefits
- Surgical & DME coverage - Verifies coverage and produces out-of-pocket estimates for surgery and DME.
- Secondary coverage detection - Detects secondary plans and coordinates benefits.
Claims & submission
- Operative-note attachment - Attaches operative notes and imaging to surgical claims.
- Claim scrubbing - Scrubs claims against payer and bundling edits.
- Claim status follow-up - Polls status and chases stuck claims.
Payments, denials & AR
- ERA auto-posting - Posts remittances and adjustments automatically.
- Surgical & DME denial recovery - Auto-appeals surgical and DME denials.
- Underpayment detection - Flags payments below contracted surgical rates.
Patient collections
- Surgery pre-payment & collection - Collects the estimated patient portion before surgery.
- Statements & payment plans - Sends statements and offers payment plans.
Front office
- Call answering & surgical scheduling - Answers calls and coordinates surgical and clinic scheduling.
- Referral intake & tracking - Captures inbound referrals and tracks them to a booked visit.
Analytics
- Surgical-yield & denial dashboards - Dashboards surgical conversion and denial trends.
What you get
- Assemble PAs for imaging, injections, surgery and DME
- Track 10- and 90-day global periods automatically
- Get surgical modifiers (24, 25, 58, 78, 79) right
- Produce accurate surgical and DME out-of-pocket estimates
- Recover surgical and DME denials
- Catch underpayments on contracted rates
Frequently asked questions
What is a global surgical period?
Major orthopedic procedures carry a 90-day global period, during which routine post-operative visits are included in the surgical payment. Billing them separately causes denials, while genuinely unrelated care must be flagged with the right modifier to be paid.
Which modifiers matter most in orthopedic billing?
Modifier 24 for unrelated E/M during a global period, 25 for a separately identifiable same-day E/M, 58 for a staged or related procedure, and 79 for an unrelated procedure during the global period. These determine whether post-op care is paid or denied.
Why do orthopedic authorizations get denied?
Most often because conservative therapy is not documented. Payers commonly require evidence of failed conservative treatment - physical therapy, injections, time - before approving MRI or surgery, so that history has to be in the authorization packet.
How is DME billed in an orthopedic practice?
Braces, boots and supports are billed with HCPCS codes and the appropriate modifiers, and many require documentation of medical necessity. Dispensing without confirming coverage and authorization is a common write-off.