Glossary · Billing

Claim

A claim is the formal request an orthopedic practice submits to a payer—Medicare, Medicaid, or a commercial insurer—seeking reimbursement for services rendered, built from CPT codes, ICD-10 diagnosis codes, modifiers, and patient demographic data. Every dollar the practice collects flows through a successfully adjudicated claim.

Verified May 8, 2026 · 7 sources ↓

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Definition

Source · Editorial summary grounded in 7 cited references ↓

In orthopedic billing, a claim is the structured electronic or paper document—most often an 837P professional claim transmitted via EDI—that translates a clinical encounter into a reimbursable transaction. It links the patient's diagnosis (ICD-10-CM codes) to the specific procedures performed (CPT codes), identifies the rendering and billing providers, and includes all modifiers needed to communicate how, where, and under what circumstances each service was delivered. Payers adjudicate the claim against their coverage policies, fee schedules, bundling edits, and global-period rules before issuing payment, denial, or a request for additional information.

Orthopedic claims are structurally more complex than those in most specialties. A single operative session can generate three to five CPT codes—for example, decompression, instrumentation, and fusion across multiple spinal levels—each requiring correct sequencing by relative value unit (RVU), accurate modifier attachment, and implant data reconciliation against the operative note before the claim leaves the practice. Major orthopedic procedures also carry a 90-day global surgery period under CMS rules, meaning post-operative evaluation and management visits performed within that window are bundled into the surgical claim and cannot be billed separately unless a recognized exception applies.

Claim construction therefore involves at least three distinct quality checks: code-level accuracy (right CPT for the documented procedure), modifier accuracy (correct two-digit modifiers appended in the right sequence), and claim-level accuracy (proper sequencing of codes, valid diagnosis linkage, and pre-submission scrubbing against National Correct Coding Initiative edits). Errors at any layer can produce a denial, a reduced payment, or a compliance flag that triggers a payer audit.

Why it matters

A flawed claim is the single most direct path to lost revenue and compliance exposure in an orthopedic practice. Incorrect code sequencing can shift the highest-RVU procedure into a secondary position, automatically triggering a 50% payment reduction on the practice's most valuable service. Billing related E/M visits inside the 90-day global period without a recognized exception modifier produces denials and, on audit, potential overpayment recoupment. NCCI edits—updated quarterly by CMS—define which orthopedic code pairs are never separately payable; failing to run claims through a pre-bill edit tool before submission is among the most audited gaps in orthopedic revenue cycle management.

Common mistakes

Where people most often go wrong with this concept.

Source · Editorial brief grounded in cited references ↓

Sequencing the lower-RVU procedure first, so the highest-value code absorbs the multiple-procedure reduction instead of the secondary code.
Submitting E/M visits performed during the 90-day global surgery period without modifier 24 (unrelated) or modifier 79 (unrelated procedure), causing automatic denial.
Billing fracture care as a separate E/M encounter when the visit is already included in the fracture care package, or the reverse—billing an E/M when fracture care CPT coding is appropriate.
Failing to run the claim through NCCI pre-bill edits, allowing invalid code pairs—such as 29880 and 29876 for the same knee compartments—to reach the payer and generate a denial.
Omitting the UDI or implant detail required by FDA rule (21 CFR 801.20) before submitting claims that include billable implants or prostheses.
Using modifier 59 to bypass a bundling edit without adequate documentation of a distinct procedural service, creating audit risk under both CMS and commercial payer policies.
Billing bilateral total knee replacement as two separate claims instead of a single claim with modifier 50 appended to CPT 27447, which forfeits the 150% bilateral reimbursement rate.

Related codes

Codes commonly involved when this concept appears in practice.

CPT

ICD-10

M17.11 M54.50

Modifiers

50 Bilateral procedure 51 Multiple procedures 59 Distinct procedural service 24 Unrelated E/M during postop 25 Significant separately identifiable E/M 79 Unrelated procedure during postop LT Left side RT Right side

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01What is the difference between a claim and a charge?

A charge is the internal record of a service and its associated dollar amount created at the practice level. A claim is the formal document transmitted to the payer requesting payment; it bundles one or more charges with diagnosis codes, modifiers, and provider identifiers into a standardized format (typically 837P) that the payer can adjudicate.

02Why do orthopedic claims have more codes per claim than most specialties?

A single orthopedic operative session routinely involves multiple distinct procedures—bone work, instrumentation, grafting, implant placement—each coded separately. Add bilateral modifiers, implant line items, and post-op supplies, and a single OR case can legitimately produce three to five CPT codes plus associated modifiers before the claim is complete.

03What happens if I bill a post-op E/M visit without a modifier during the global period?

The payer will deny the claim because CMS bundles all related post-operative evaluation and management into the surgical fee for 90-day global procedures. To be paid for a visit during that window, the visit must be unrelated to the surgery (modifier 24) or represent a separately identifiable service (modifier 25 for same-day minor procedures), and documentation must clearly support the distinction.

04What are NCCI edits and how do they affect an orthopedic claim?

The National Correct Coding Initiative (NCCI), maintained by CMS and updated quarterly, specifies which CPT code pairs cannot be billed together because one procedure is considered inclusive of the other. In orthopedics, common examples involve knee arthroscopy codes representing overlapping compartments. If a claim includes a prohibited code pair without an approved modifier and clinical justification, the payer will deny the secondary code.

05How should bilateral procedures be claimed?

Bill the bilateral service on a single claim line with modifier 50 appended to the CPT code—for example, 27447-50 for bilateral total knee replacement performed in the same session. Most payers reimburse bilateral claims at 150% of the single-procedure rate. Submitting two separate claims for each side is incorrect and typically results in one claim being denied as a duplicate.

06Which orthopedic CPT codes are most frequently audited?

CPT codes 27507 (femur fracture repair), 20610 (major joint injection or aspiration), and 29881 (knee arthroscopy with meniscectomy) are among the most audited orthopedic codes due to documentation inconsistencies, bundling errors, and high claim volume. Practices billing these codes should ensure operative notes fully support the specific procedure performed and that modifier use is defensible.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

01
adsc.com
https://www.adsc.com/blog/orthopedic-medical-billing-the-complete-guide-for-practices
02
transcure.net
https://transcure.net/medical-billing/orthopedic/
03
aapc.com
https://www.aapc.com/blog/35663-combat-common-denials-in-orthopedic-coding/
04
mbwrcm.com
https://www.mbwrcm.com/the-revenue-cycle-blog/orthopedic-surgery-coding-cheatsheet
05
aaos.org
https://www.aaos.org/quality/coding-and-reimbursement/
06CMS Global Surgery Policy (CMS IOM Publication 100-04, Chapter 12)
07CMS National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services

Mira AI Scribe

Mira's documentation layer participates directly in claim construction by validating that the structured encounter output supports a clean, submittable claim before charge entry. Specifically, Mira checks that every CPT code selected during the encounter has a linked, supporting ICD-10-CM diagnosis; that procedures performed in the same operative session are sequenced highest-RVU first; that applicable modifiers (e.g., 51 for multiple procedures, 50 for bilateral services, 59 for distinct procedural services) are flagged for coder review when clinical documentation supports them; and that post-operative visit documentation is tagged against the procedure date so global-period rules can be applied correctly. When implants are documented intraoperatively, Mira prompts for UDI capture so billing staff can reconcile device data against the operative note before submission. Mira does not submit claims directly but produces a pre-bill summary that surfaces NCCI bundling conflicts, missing modifiers, and sequencing anomalies so the coder can resolve them prior to the claim leaving the practice.

See Mira's approach

Related terms

Modifier Coding

A modifier is a two-character code—numeric, alphanumeric, or alpha—appended to a CPT or HCPCS code to signal that a service was performed under circumstances that differ from the standard description, without altering the fundamental meaning of the code itself.

CPT code Coding

A CPT code is a standardized five-digit numeric code, maintained by the AMA, that identifies a specific medical or surgical service for billing and reimbursement purposes. In orthopedics, CPT codes cover everything from office visits and joint injections to complex spinal fusions and total joint replacements.

ICD-10-CM Coding

ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) is the U.S. diagnosis coding system used on every claim to communicate why a service was performed, establish medical necessity, and support reimbursement. Maintained by CMS and CDC, it has been required for all HIPAA-covered entities since October 1, 2015.

Relative Value Unit (RVU) Reimbursement

A Relative Value Unit (RVU) is a numeric weight assigned to each CPT code that quantifies the resources required to perform a medical service; when multiplied by a conversion factor and geographic adjustments, it determines Medicare and commercial payer reimbursement.

Prior authorization Billing

Prior authorization (PA) is a payer requirement that a provider obtain approval before delivering a specific service, procedure, or item—otherwise the claim will be denied regardless of medical necessity. Approval is granted when submitted clinical documentation meets the payer's coverage criteria.

Unbundling Coding

Unbundling is the incorrect practice of billing multiple separate CPT or HCPCS codes for components of a procedure that a single, more comprehensive code already covers—resulting in inflated reimbursement claims and potential fraud exposure.