Why Orthopedic Surgery Claims Deny for Bundled Procedures
Short answer: Orthopedic claims deny for bundling when payers apply National Correct Coding Initiative (NCCI) edits that treat a secondary procedure as
Read the articleEmail: info@webillhealth.com | Call: +1 (425) 818 9351
Business hours: Monday to Friday, 8am to 9pm EST
Case study · Orthopedics
$300K more in annualized collections for a 5 provider orthopedic practice
Denials were running at 13% and $285K sat in A/R past 90 days. Patients were paying only 75% of what they owed. Ninety days after WeBill Health took over the revenue cycle, every one of those numbers had moved.
5 providers$2M annual collections beforeResults measured at day 90
+$25KMonthly collections, from $166.7K to $191.7K
4.8%Denial rate, down from 13%
$145KCleared from A/R over 90 days
90%Patient balances collected, up from 75%
The practice
Care was delivered. Payment was not keeping up.
A five provider orthopedic group with surgeries, injections and follow up visits all moving through global periods and payer edits. The largest claims were the ones most likely to stall.
| Specialty | Orthopedics |
|---|---|
| Providers | 5 |
| Annual collections | $2M, about $166.7K a month |
What we found in the audit
13% of claims denied
Too many claims came back unpaid, with the same denials repeating month after month.
$285K stuck past 90 days
Earned money was sitting in aging A/R with no one working it by payer or by filing deadline.
91% clean claim rate
Too many claims needed rework before a payer would even process them.
75% of patient balances collected
Copays and balances were left behind at checkout and never recovered.
What WeBill Health changed
Six fixes before the visit, in the coding and after submission
Every claim received human pre submission review by orthopedic coding experts, checked against our payer rule libraries for each carrier this practice bills.
Before the procedure
Authorize and verify first
- Prior authorization secured for surgery and advanced imaging
- Eligibility verified and patient balances collected before the procedure
Coding
Respect global periods and payer edits
- Global period review so visits inside a surgical global are billed only when separately payable
- Procedure coding checked against payer edits and modifier rules before submission
After submission
Collect the high dollar claims
- Underpayments identified against contracted rates
- High dollar A/R worked first, by payer and by age
90 day results
Before and after WeBill Health
Denial rate
Lower is betterClean claim rate
Higher is betterA/R over 90 days
Lower is betterPatient balances collected
Higher is betterMonthly collections
Higher is betterEvery bar starts at zero. Figures come from the practice's own billing reports, comparing the baseline month with month three.
Where the $300K comes from
An extra $25K collected every month
Monthly collections rose from $166.7K to $191.7K by day 90. Held for a full year, that is $300K the practice collects on care it was already delivering.
The gain came from specialty specific coding and fewer days in A/R. Fewer claims were denied, and balances that had aged past 90 days were finally collected.
Monthly collections before$166,700
Monthly collections at day 90$191,700
Increase per month$25,000
Annualized increase$300,000
Net return on the WeBill Health fee161%
Net return is the annualized increase in collections, minus the annual WeBill Health fee, divided by that fee. It is calculated before any savings from the practice's previous billing arrangement.
The math
Where the $25,000 a month came from
Estimated breakdown, built from orthopedic billing benchmarks and 2026 Medicare rates, tied to this practice's measured before and after figures. Each line is a claim count multiplied by what those claims pay. A/R cleared from the old backlog is reported separately and is not part of this monthly gain.
| Change | Added a month |
|---|---|
| Denials stopped before they happenedAbout 834 claims a month at an average of $200 collected. Cutting the denial rate from 13% to 4.8% means 68 fewer denials a month. Before, about half of denials were never reworked, so 34 of those claims are now paid that were not. | $6,800 |
| Patient balances collectedPatients owe about $25,000 a month in copays, deductibles and coinsurance. Collection rose from 75% to 90%. | $3,750 |
| Separate visits paid on injection daysVisits with a separate evaluation billed with modifier 25 beside a 20610 or 20550 injection, 86 a month at about $108 each. | $9,288 |
| Underpaid claims recovered89 claims a month paid below the contracted rate, short by an average of $58, now appealed and recovered. | $5,162 |
| Added collections a month at day 90 | $25,000 |
Prior authorization moved to WeBill Health as well. The AMA 2025 survey puts that work at 13 hours a week per physician, or about 65 hours a week for 5 providers. At the national median wage for medical administrative staff ($45,930 a year, BLS May 2025) plus benefits, that workload is worth about $106,623 a year in staff time.
Codes and conditions
The claims behind these numbers
| Visit type | Codes and rules | Typical conditions (ICD 10) |
|---|---|---|
| Visit plus joint injection | 99213 or 99214 with modifier 25 only for a separate evaluation, plus 20610 (0 day global) | Primary osteoarthritis, right knee M17.11 |
| Tendon sheath injection | 20550 (0 day global), laterality modifiers RT or LT | Trigger thumb, right thumb M65.311; impingement of right shoulder M75.41 |
| Viscosupplement series | J7325 with NDC, units and JW or JZ, prior authorization on most commercial plans | Primary osteoarthritis, right knee M17.11 |
| Imaging and follow up inside a surgical global | 73562 knee X ray; modifier 24 for unrelated visits, 79 for unplanned returns, 57 for the decision for surgery | Pain in right knee M25.561; low back pain M54.50 |
What it costs
The 5% fee against the cost of doing this in house
This practice's WeBill Health rate is 5% of collections. At $191,700 a month that is $115,020 a year. Here is what the same work costs a 5 provider practice that staffs it in house, before software and clearinghouse fees.
| Item | Per year |
|---|---|
| In house billing staff2 billers for 5 providers (MGMA: about one per two to three providers) at $73,160 each, the BLS median of $51,140 plus benefits | $146,320 |
| Prior authorization staff time13 hours a week per physician (AMA 2025), 65 hours a week, at the BLS median for medical administrative staff plus benefits | $106,623 |
| In house cost | $252,943 |
| WeBill Health fee, 5% of collections | $115,020 |
| Saved against in house staffing | $137,923 |
| Added collections a year | $300,000 |
| Better off each year with WeBill Health | $437,923 |
What other orthopedic practices can take from this
Three orthopedic billing gaps worth checking this week
Know what the global period already pays for
Major surgery carries a 90 day global period. Routine follow up visits inside it are included, while an unrelated problem needs modifier 24 and the decision for surgery needs modifier 57.
Apply modifiers only when the note supports them
Procedure pairs flagged by NCCI edits are paid separately only when documentation shows distinct services. Modifier 59 or an X modifier without that support invites an audit.
Authorize before the MRI and the surgery
Most payers require prior authorization for advanced imaging and elective surgery. The claim fails even when the care was necessary.
Your practice next
Find out what your orthopedic practice is leaving uncollected
The Revenue Defense Audit reviews your denials, aging A/R and patient collections the same way we did here. You get a written report that ranks the fixes by dollars at stake. We reply within one business day.
Questions
About this case study
How fast did the results appear?
Every figure on this page was measured at day 90, comparing the practice's baseline month with its third month on WeBill Health.
Why is the practice not named?
We protect our clients' privacy. The figures come from the practice's own billing reports.
What drove the biggest change?
The denial rate. Cutting denials from 13% to 4.8% meant far more claims were paid the first time, which lifted monthly collections and stopped new balances from piling up in aging A/R.
Does WeBill Health work with other orthopedic practices?
Yes. Orthopedics sits in our Procedure and Surgical billing group. Every account is handled by coding experts who work orthopedic claims every day.
We bill inside the system you already use
Our billers and coders work every day in the five EHR, EMR and practice management systems most used in orthopedics. You keep your software, and we take over the billing inside it.
EHR, EMR and practice management
- MOModMed
- NENextGen Healthcare
- ATathenaOne
- PHPhoenix Ortho
- NENextech
Clearinghouses
- OPOptum
- AVAvaility
- WAWaystar
- TRTriZetto
- OFOffice Ally
Using a system that is not listed here? Tell us on the audit call. Product names are trademarks of their owners and appear here only to show the systems we work in. No partnership or endorsement is implied.
Worth reading
View all articlesWill My Medicare Patients Lose Coverage Over Citizenship Status in 2027?
CMS says Medicare eligibility narrows by citizenship status, with terminations starting in 2027. Here is how independent practices can verify eligibility now
Read the articleThe Denial Root Cause Playbook
Find the three denial patterns costing you most, trace each to its cause with the CARC code map, and close it at source. Appeal deadline table, checklist and worksheet included.