For orthopedic and musculoskeletal practices

The Operation Was Paid Once. What About the Ninety Days After It?

Orthopedics is one of the few specialties where a large share of the work is performed after the claim has already been paid. The global surgical package pays for the operation and for the recovery attached to it, which means the practice's revenue question is not what was billed but what was correctly carved out of the package and what was correctly left inside it.

See What Your Revenue Data Is Telling You Talk With CareVixis

Start with the free CareVixis practice assessment. No email required.

U.S. team U.S. data centers Live support 24/7 Zero outsourcing Work directly with your team

The Operation Is Paid Once.

And that single payment covers more than the operation. The recovery attached to it is already inside the money you have been paid.

Including the Complications.

Postoperative E/M related to recovery is inside the package. So is E/M related to complications of the surgery. Real work, already paid for.

Two Characters Decide the Difference.

Modifier 24, 58, 78 or 79 is what separates work that belongs outside the package from work that does not. Billed without one, an additional procedure in the global period is not separately paid.

The Surgeon Already Knows the Answer.

Whether it was staged, unrelated, or a return to theatre is clear at the point of care. What is usually missing is the path from that knowledge to the claim.

So the Denials Repeat.

Not randomly. By surgeon, by payer, by the same handful of decisions, every month, in a specialty where each claim is worth a lot.

Orthopedic denials are rarely arguments about medicine. They are arguments about which payment the work already belonged to.

The detail

Everything below is the evidence for what you just read.

What is actually included in the global surgical package?

For major and minor surgical procedures, postoperative evaluation and management services related to recovery from the procedure are included in the global surgical package, and so are E/M services related to complications of the surgery.[1]

That second clause is the one that surprises people. A complication brings the patient back, generates real clinical work, and is still inside a payment that has already been made. Getting paid for it depends entirely on whether the circumstances meet a published exception and whether the right modifier says so.

What the rules actually say

The Modifiers That Move Work Out of the Package

Everything below is as Medicare publishes it, cited at the foot of this page.[1][2] These are the published definitions, not a CareVixis interpretation, and not a prediction of how a specific payer will adjudicate a specific claim.

Published rules and coding families for this specialty, cited below. CareVixis states them as the source publishes them and does not paraphrase a payer policy into a promise.
Where it bites	What the published rule says
Modifier 24	An unrelated evaluation and management service by the same physician during a postoperative period.
Modifier 25	The decision to perform a minor surgical procedure is separately reportable with modifier 25 where the E/M service is significant and separately identifiable.
Modifier 58	Established to facilitate billing of staged or related surgical procedures performed during the postoperative period of the first procedure.
Modifier 78	Used for return trips: a return to the operating room for a related procedure during a postoperative period.
Modifier 79	An unrelated procedure by the same physician during a postoperative period.
What happens without one	MACs do not allow separate payment for an additional procedure within a global surgery fee period furnished during the postoperative period of a prior procedure if it is billed without modifier 58, 78 or 79.

Read the last row again, because it is the whole commercial problem in one sentence. The work is not denied because it was unnecessary. It is denied because the claim did not carry the two characters that distinguish it from work already paid for.

The gap

A Decision Made in Clinic, Priced in the Billing Office

The surgeon knows perfectly well whether today's visit relates to the previous operation, whether this is a staged procedure that was always planned, and whether the patient is back in theatre for a complication or for something entirely different. That knowledge exists at the moment of care.

What usually does not exist is a reliable path from that knowledge to the two characters on the claim. The operative note describes the clinical reality. The claim is assembled later, often by someone reading that note without the conversation that surrounded it.

The result is a specialty where denials cluster around a small number of modifier decisions, repeat monthly, and are individually arguable but collectively very expensive.

What a surgical schedule shows

Cases performed and by whom.
Implants and supplies used.
Theatre time and turnaround.
Charges dropped against the case.

What it does not show

Which visits fell inside a global period.
Which of those should have carried 24, 58, 78 or 79.
Which denials were modifier decisions rather than coverage decisions.
Whether the same modifier error is recurring by surgeon or by payer.

Where this specialty loses money

Six Ways Orthopedic Work Goes Unpaid

Each of these describes clinical work that was performed, documented and clinically appropriate. The failure is downstream of the medicine.

The unrelated visit that looked related

A postoperative patient is seen for something with nothing to do with the operation. Without modifier 24 the payer reads it as included and pays nothing.

The staged procedure billed as a new one

The second stage was always the plan. Billed without modifier 58 it looks like a duplicate, and is treated as one.

The return to theatre

A related procedure requiring a return to the operating room during the postoperative period. Modifier 78 exists precisely for this and is frequently omitted.

Prior authorisation obtained for the wrong thing

Authorisation was secured for the planned procedure. Intraoperative findings changed the procedure, and the authorisation no longer matches the code billed.

Imaging denied on medical necessity

Advanced imaging is ordered on clinical judgement and adjudicated against a written coverage policy. The two do not always agree, and the appeal is rarely filed.

Implant and supply costs unreconciled

High-cost items are used in theatre and either billed separately or absorbed. Which of the two happened is often nobody's specific job to confirm.

The practical version of all six: orthopedic revenue is unusually concentrated in a small number of high-value claims, and a single recurring modifier habit can cost a practice more than an entire category of small denials elsewhere.

Conceptual workflow

Where This Fits Around What You Already Run

An illustration of the general flow for an orthopedic practice, not a description of any particular practice or payer policy.

Consultation and imagingWhere coverage policy and clinical judgement first meet.
Authorisation for the planned procedureSecured against what is expected to happen in theatre.
The operationWhich may differ from the plan, for entirely good reasons.
The global period beginsRelated recovery care, and care for complications, is now inside a payment already made.
Remittance and denials come backOften about modifiers rather than about medicine.
Root cause, not just reworkWhether this is one claim or a habit repeating across a surgeon or a payer.
The pattern, and the fixChanging what happens at the point of documentation, not just at the point of appeal.

A framework you can use on anyone

What Should an Orthopedic Practice Ask a Billing Company?

Nine questions for whoever bills for you now, and for CareVixis. The first three separate a company that understands surgical billing from one that processes claims.

How do you decide between 24, 58, 78 and 79?

You want a process that reads the operative note and asks the surgeon when it is ambiguous, not a default.
Do you track which visits fall inside a global period?

If the system cannot tell you that, every postoperative E/M decision is being made blind.
What happens when the procedure performed differs from the one authorised?

This is routine in orthopedics. A company without a defined answer will simply absorb the denial.
Do you appeal imaging denials, or write them off?

Ask for the appeal rate and what it is measured against.
How are implants and high-cost supplies reconciled?

Specifically: who confirms that what was used in theatre matches what was billed.
Do you perform root cause analysis, as a defined process?

One corrected modifier gets this claim paid. Finding the habit stops the next quarter of them.
Can you work with the systems we already run?

Changing a surgical practice's EHR to fix a billing problem is a large answer to a small question.
What visibility do we get, and how often?

Denials by reason and by surgeon, without having to ask someone to build the report.
Is the work performed in the United States?

CareVixis is 100% US-based with zero outsourcing. Ask anyone else the same question and get the answer in writing.

Using Orthopedics? Keep It.

Your EHR, your imaging and your theatre scheduling are yours. Nothing on this page requires replacing any of them, and a migration would answer none of the questions above.

Keeping your system is a supported outcome, not a fallback. If you later want to move to the CareVixis platform, that move may be offered at no additional migration charge. Keeping the software you already have carries no monthly software fee from CareVixis.

Keep your systems. Change what happens between the operative note and the claim.

See What VixisIQ™ Does See How VixisTrace™ Works

Straight answers

Questions Orthopedic Practices Ask

Are complications of surgery included in the global surgical package?

Yes. For major and minor surgical procedures, postoperative E/M services related to recovery from the procedure are included in the global surgical package, and so are E/M services related to complications of the surgery. Work generated by a complication is therefore inside a payment that has already been made, unless the circumstances meet a published exception and the claim carries the modifier that says so.

What happens if we bill a procedure in a global period without a modifier?

MACs do not allow separate payment for an additional procedure within a global surgery fee period that is furnished during the postoperative period of a prior procedure and billed without modifier 58, 78 or 79. The work is not judged unnecessary; it is simply treated as already paid for.

What is the difference between modifier 58 and modifier 78?

Modifier 58 was established for staged or related surgical procedures performed during the postoperative period of the first procedure. Modifier 78 is for return trips, meaning a return to the operating room for a related procedure during a postoperative period. The distinction is whether the second procedure was planned as a stage or required an unplanned return.

Do you handle prior authorisation when the procedure changes in theatre?

Yes, and it is one of the more common recurring problems in orthopedic billing. Authorisation is secured against the planned procedure; intraoperative findings can change what is actually performed. CareVixis treats the mismatch as a defined workflow rather than as an exception to be absorbed, because in this specialty it is not an exception.

Do we have to change our EHR to work with CareVixis?

No. CareVixis can manage the revenue cycle around the systems a practice already uses. If your EHR, imaging and theatre scheduling work for your surgeons, keep them. A practice that later wants to consolidate on the CareVixis platform can do that at its own pace.

Keep Orthopedics. Add Revenue Intelligence.

Keep your EHR. Keep your clearinghouse. Change what happens between the operative note and the claim, and what happens to a denial after it comes back.

Take the Free Practice Assessment Talk With CareVixis

Free. No obligation. No email required.

Sources

Centers for Medicare & Medicaid Services, Global Surgery Booklet, MLN907166. Source of the statement that postoperative E/M services related to recovery, and E/M services related to complications of the surgery, are included in the global surgical package for major and minor surgical procedures, and of the definitions of modifiers 24, 25, 58, 78 and 79. cms.gov. Accessed 20 September 2026.
Centers for Medicare & Medicaid Services, National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 4 (2026). Source of the treatment of modifiers 24, 25, 57, 58, 78 and 79 as NCCI PTP-associated modifiers, and of the statement that A/B MACs do not allow separate payment for an additional procedure within a global surgery fee period billed without modifier 58, 78 or 79. cms.gov. Accessed 20 September 2026.
American Academy of Orthopaedic Surgeons, Medicare Sharpens Focus on the Global Surgical Package. Corroborating specialty-society commentary on the global surgical package and its postoperative scope. aaos.org. Accessed 20 September 2026. A professional association source, used here for specialty context rather than for any rule stated above.

CareVixis publishes no denial rate, recovery rate or revenue figure for orthopedic practices. The rules above are what the published sources say. What they are worth to a particular practice depends on its case mix, payer contracts and current documentation process, and we would rather look at yours than quote an average at you.

The CareVixis Model, Applied to Medical Billing for Orthopedic Practices

The six CareVixis pillars stay consistent (Revenue Cycle, Credentialing, Technology, Communications, Operations and Growth) while the workflow adapts to this specialty's documentation, coding, payer and operational requirements. Keep the systems that work for you; CareVixis connects responsibility around them.