Orthopedic Billing Guide: 2026 CPT Codes, Global Periods and NCCI Rules

• The global indicator decides the E/M modifier: 57 for the decision for a 090-day procedure, 25 for separate work on the day of a 000 or 010 procedure.
• The first cast is inside the fracture code. Casting is billed on its own only for initial care without definitive treatment (NCCI ch. IV §G.6–8).
• Surgical arthroscopy includes diagnostic arthroscopy, and a scope converted to open is billed as the open procedure only (§E.1–3).
• Spine is coded per level with add-on codes, one primary code per region through one incision (§F.4–5).
• Bilateral is one line with modifier 50 at 150%; multiple procedures pay 100% then 50% (Claims Processing Manual ch. 12 §40.6–40.7).

The American Academy of Orthopaedic Surgeons tracks coding changes for its members in its Coding and Reimbursement resources (read November 9, 2026).

Every procedure on the Medicare fee schedule carries a global indicator, shown in the PFS Look-Up Tool. CMS’s Global Surgery booklet (MLN907166) and NCCI chapter IV §B define them:

The package includes preoperative visits after the decision to operate (the day before for major procedures, the same day for minor ones), the operation, follow-up visits for recovery, postoperative pain management by the surgeon, complications that do not need a return to the OR, and the routine work: dressing changes, removal of sutures, staples, drains, casts and splints. It excludes the visit that decides on major surgery, unrelated visits, diagnostic tests, treatment of the underlying condition, and a return to the OR for a complication.

Florida practices must report 99024

NCCI chapter IV §B states the rule. For a 090-day major procedure, an E/M the same day to decide whether to operate is reportable with modifier 57; other preoperative visits that day are in the package. For a 000- or 010-day minor procedure, the decision to do the procedure is part of the procedure, and only a significant, separately identifiable E/M is reportable, with modifier 25. Different diagnoses are not required, and a new patient alone does not justify a visit. CMS adds that contractors may not pay 57 on the day of or day before a 000- or 010-day procedure (MLN907166).

Postoperative visits for recovery or complications are in the package. A visit for an unrelated problem during the global period takes modifier 24, with documentation that it is unrelated.

Injecting local anesthetic for a musculoskeletal procedure is never billed on its own. A separate, distinct injection that is not anesthesia for the procedure may be reported with a PTP-associated modifier. Where the code descriptor includes imaging guidance, a separate guidance code is not billed (§I.29).

Fracture and dislocation codes are chosen by site and by type of treatment: closed (with or without manipulation), percutaneous or open. They include the first immobilization device. The NCCI rules from chapter IV §G:

• Initial cast, splint or strap is included in the fracture code, and so is its later removal by the same practice. Removal and repair codes 29700–29750 are reported only when someone else applied the device (§G.1, §G.6–7).
• Initial care only. A physician who treats with a cast or splint as an initial service, with no definitive treatment and no plan to provide follow-up, may report the E/M, the casting code and a supply code from Q4001–Q4051 (§G.8).
• Casting is a 000-day minor procedure. An E/M with it must be significant and separately identifiable (§G.9).
• One repair code per site. Closed, percutaneous and open codes for the same site are mutually exclusive, and a failed closed reduction converted to open is billed as the open procedure only (§G.12, §G.15).
• Multiple fractures under one cast without manipulation are one closed-treatment code. Closed treatment of several metacarpals in one hand is one unit of 26600, and the same applies to carpals, tarsals and metatarsals (§G.16, §H.9–10).
• Manipulation under anesthesia during another procedure in a related area (22505, 23700, 27275, 27570, 27860) is not separate (§G.14).
• Dressings are not casts. Casting codes are not reported for a dressing after a procedure, or with any musculoskeletal surgery code on the same area (§G.2–3).

NCCI chapter IV §E.1–3: surgical arthroscopy includes diagnostic arthroscopy, a scope used to assess the field is not separate, and a scope converted to open is billed as the open procedure only. A diagnostic arthroscopy whose findings lead to an open procedure may be reported, with modifier 58.

Coverage is a separate question. Medicare’s NCD 150.9 does not cover arthroscopic lavage alone for the osteoarthritic knee, or debridement when knee pain is the only symptom or the arthritis is severe (Outerbridge grade III or IV); other cases are left to the contractor.

Spine codes come in families: a primary code for the first level in a region and an add-on code for each additional level. NCCI chapter IV §F.4–5 says contiguous levels take one primary code and add-ons; separate incisions in different regions may each take a primary code. Vertebroplasty (22510–22512) and vertebral augmentation (22513–22515) take one primary code and add-ons whether or not the levels are contiguous.

• Decompression at the fused level. 63042 or 63047 is not paid with 22630 or 22633 at the same interspace; at a different interspace, use 59 or XS (§F.9).
• Instrumentation. One anterior or posterior instrumentation code (22840–22847) per skin incision (§F.10), and anchoring of an interbody device (22853, 22854) is not separate instrumentation (§F.11).
• Grafts. 20931, 20937 and 20938 are one unit per operative session regardless of levels fused (§H.4).
• Included in the surgeon’s work: fluoroscopy 76000 unless CPT says otherwise, manipulation 22505, exploration 22830 in the same area, and intraoperative neuromonitoring (95940, 95941, G0453) by the operating surgeon. A different physician monitoring may bill it (§F.1–3, §F.6).

Removal of implants (20670 superficial, 20680 deep) is one unit for all hardware removed from one anatomic site, through one incision or several, and it is not separate when it is an integral part of another procedure such as revision of a nonunion (§G.10, §H.3).

A practitioner who did not do the surgery and provides postoperative visits without a formal transfer of care bills the E/M, with add-on G0559 for the postoperative follow-up resources (MLN907166).

Each rule above becomes a denial when it is missed. The ones this guide covers: a decision-for-surgery visit sent without 57 and bundled into the package, a 57 on a minor procedure, a cast billed with the fracture code that includes it, a second shoulder arthroscopy code on the same shoulder pushed through with 59, a spine add-on paired with the wrong primary code, more than one unit of 20610 for one joint, and a 78 billed where 58 or 79 was the correct statement. How a denied claim gets worked once it comes back is covered on our denial management page.

• Medicare NCCI Policy Manual 2026, Chapter IV: Surgery, Musculoskeletal System (revision date January 1, 2026; read November 9, 2026)
• Medicare NCCI Policy Manual 2026, Chapter I: General Correct Coding Policies, §E Modifiers (read November 9, 2026)
• CMS MLN907166, Global Surgery (December 2025)
• Medicare Claims Processing Manual, Chapter 12, §40.4, §40.6, §40.7 (Rev. 13753, issued May 7, 2026)
• CMS fact sheet: CY 2026 Medicare Physician Fee Schedule final rule (CMS-1832-F) (October 31, 2025)
• NCD 150.9: Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (read November 9, 2026)
• CMS, Global Surgery Data Collection (read November 9, 2026)
• American Academy of Orthopaedic Surgeons, Coding and Reimbursement (read November 9, 2026)

CPT codes and descriptors are from the AMA CPT code set. This guide does not state fee amounts; check your Medicare contractor’s fee schedule and your payer contracts.

When do I use modifier 57 instead of modifier 25 in orthopedics?

Modifier 57 goes on the E/M when the visit is the decision to perform a 090-day major procedure on the same day or the day before. Modifier 25 goes on a significant, separately identifiable E/M on the day of a 000- or 010-day minor procedure such as an injection or closed treatment. CMS says contractors may not pay 57 with a 000- or 010-day procedure.

Can I bill a cast or splint with fracture treatment?

Not the first one. NCCI chapter IV says closed, percutaneous and open fracture and dislocation codes include the initial cast, splint or strapping. When a physician gives only initial care with no definitive treatment and expects someone else to take over, the E/M, the casting code and the supply code Q4001–Q4051 may be reported.

How many units of 20610 can I bill for one shoulder?

One. The unit of service for 20600–20611 is a joint and its surrounding bursae. Arthrocentesis of the shoulder plus two bursae of the same shoulder is one unit of 20610 under NCCI chapter IV §H.7.

Is diagnostic arthroscopy billable with surgical arthroscopy?

No. Surgical arthroscopy includes diagnostic arthroscopy. A diagnostic arthroscopy is separately reportable only when its findings lead to a decision to do an open procedure, with modifier 58 and a record that shows why the diagnostic scope was needed.

Can G0289 be billed with a knee meniscectomy?

Only for removal of a loose or foreign body in a different compartment of the same knee. 29880 and 29881 already include chondroplasty in any compartment, so G0289 is never reported for chondroplasty with them, and never for work in the same compartment.

How are multi-level spinal fusions coded?

One primary code for the first interspace and an add-on code for each additional interspace through the same incision. 22614 adds to 22600, 22610, 22612, 22630 or 22633; 22632 adds to 22612, 22630 or 22633; 22634 adds to 22633. A separate incision in a different region may start a new primary code.

How are bilateral orthopedic procedures billed to Medicare?

On one claim line with modifier 50 and one unit, unless the CPT descriptor already says bilateral. Medicare pays bilateral-eligible procedures at 150% of the fee schedule amount. An ambulatory surgical center reports two lines with RT and LT instead.

Which modifier applies when the patient returns to the OR during the global period?

Modifier 78 for an unplanned return for a related procedure, which Medicare pays at the intra-operative portion and which does not start a new global period. Modifier 58 is for a staged or planned procedure and modifier 79 for an unrelated one; both start a new global period.

What changed for orthopedic billing in 2026?

The 2026 NCCI Policy Manual took effect January 1, 2026. The CY 2026 fee schedule set conversion factors of $33.57 and $33.40, applied a -2.5% efficiency adjustment to non-time-based services including surgery, and recognized more indirect practice expense in office settings than facility settings.