GoHealthcare Knowledge Center | Orthopedic Surgery

Orthopedic Procedure Library

A structured index of orthopedic, spine, joint, peripheral nerve, neuromodulation, interventional, ASC, diagnostic, and durable medical equipment guides.

Developed by Pinky Maniri, MSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in Healthcare A.I. Governance | Founder and Chief Executive Officer, GoHealthcare Practice Solutions

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Important Notice This page is an educational and operational reference. It is not a surgical technique manual, a substitute for physician clinical judgment, coding advice for a specific claim, or legal advice. Coverage, authorization, coding, and payment requirements vary by payer, product line, state, contract, and date of service. Verify all requirements before reliance.

The Orthopedic Procedure Library organizes GoHealthcare's procedure-specific operational guides by service family. Each companion guide is designed to address medical necessity, payer policy, prior authorization, documentation, coding fundamentals, reimbursement considerations, denial prevention, and workflow optimization.

Specialty Orthopedic Surgery

Focus Operations, payer policy, documentation, coding, compliance, and performance

Audience Physicians, APPs, administrators, PA/UM, RCM, ASCs, hospitals, and executives

Verification Standard Confirm current payer, CMS, coding, contractual, and state requirements

Page Contents

Orthopedic Service Families Procedure Categories and Related Resources Frequently Asked Questions Authoritative References

Orthopedic Specialty Center

Orthopedic Surgery Specialty Guide Executive entry point for orthopedic service-line operations and the complete Orthopedic Surgery Specialty Hub. Orthopedic Practice Operations Operating model, scheduling, site-of-service, staffing, and pre-surgical huddle controls. Orthopedic Prior Authorization Decision pathways, payer criteria, authorization workflow, peer-to-peer, and appeals. Orthopedic Revenue Cycle Management Revenue leakage controls, financial clearance, payment changes, and RCM performance. Orthopedic Documentation Requirements Clinical documentation checklists for authorization, coding, payment, and audit defense. Orthopedic Coding and Billing Fundamentals CPT families, diagnosis coding, modifiers, place of service, and coding risk. Orthopedic Compliance and Audit Readiness Federal and payer compliance, audit risk, governance, and corrective controls. Orthopedic KPIs and Performance Management Definitions, owners, thresholds, and interventions for orthopedic performance metrics. AI Governance in Orthopedic Practices AI use cases, governance requirements, payer-side AI, and human accountability. Orthopedic Best Practices and Common Mistakes Best practices, common mistakes, operational pearls, pitfalls, and takeaways. Orthopedic Procedure Library Procedure categories and links across the GoHealthcare MSK Specialty Procedure Library. Orthopedic Surgery FAQs Twenty-five substantive orthopedic operations, payer, documentation, coding, and billing FAQs.

Orthopedic Service Families

The service families that drive operational load

Service family	Representative scope	Dominant operational risk
Large joint arthroplasty	Primary and revision hip, knee, and shoulder replacement; partial knee arthroplasty; reverse shoulder arthroplasty	Conservative therapy documentation; radiographic grading; site-of-service determination; episode cost accountability
Knee and shoulder arthroscopy	Meniscectomy and meniscus repair; chondroplasty and debridement; rotator cuff repair; labral repair; subacromial decompression	Medical necessity for debridement in the presence of osteoarthritis; NCD 150.9 and WISeR exposure; imaging-to-procedure alignment
Ligament reconstruction	Anterior and posterior cruciate ligament reconstruction; multiligament and revision reconstruction	Graft and implant coding; assistant-at-surgery and co-surgery documentation; concurrent procedure bundling
Spine surgery	Decompression, discectomy, laminectomy, foraminotomy, fusion by approach, revision fusion, sacroiliac joint fusion	Highest authorization denial density in the specialty; cervical fusion is a WISeR category; spinal fusion is a TEAM episode; sacroiliac arthrodesis reporting changed for CPT 2026
Fracture and trauma care	Open and closed treatment with and without fixation; hip and femur fracture surgery; periprosthetic fracture	Emergent care rarely requires prior authorization but frequently requires retrospective notification; surgical hip femur fracture treatment is a TEAM episode
Hand, wrist, and peripheral nerve	Carpal tunnel release; cubital tunnel release; ulnar nerve transposition; trigger finger; Dupuytren; small joint arthroplasty	Electrodiagnostic and conservative therapy prerequisites; small joint surgery is governed by a separate delegated vendor guideline; endoscopic variants can lack specific CPT codes
Foot and ankle	Bunion correction; ankle arthroscopy; ankle fusion and replacement; tendon repair	Cosmetic-versus-functional documentation; laterality and multiple-digit modifier accuracy
Interventional and adjunctive	Image-guided joint injection and aspiration; viscosupplementation; biologics; durable medical equipment and orthoses	Frequency limits; product-specific coverage; supplier standards and documentation for braces and orthoses

Procedure Categories and Related Resources

The GoHealthcare MSK Specialty Procedure Library™ provides procedure-specific guides built to the same standard as this specialty hub guide. The table below maps the orthopedic and adjacent musculoskeletal guides available in the Library. Visit the GoHealthcare Procedure Library for the current live guide index.

Category	Guides in the Library
Orthopedic surgery — shoulder	Shoulder Arthroscopy · Rotator Cuff Repair · Labral Repair · Shoulder Replacement · Reverse Shoulder Arthroplasty
Orthopedic surgery — knee	Knee Arthroscopy · Anterior Cruciate Ligament Reconstruction · Posterior Cruciate Ligament Reconstruction · Meniscus Repair · Partial Knee Arthroplasty · Total Knee Arthroplasty
Orthopedic surgery — hip	Hip Arthroscopy · Hip Arthroplasty
Peripheral nerve surgery	Carpal Tunnel Release · Cubital Tunnel Release · Ulnar Nerve Transposition · Peripheral Nerve Decompression
Lumbar spine surgical	Microdiscectomy · Laminectomy · Laminotomy · Foraminotomy · Posterior Lumbar Interbody Fusion · Transforaminal Lumbar Interbody Fusion · Anterior Lumbar Interbody Fusion · Lateral Lumbar Interbody Fusion · Oblique Lumbar Interbody Fusion · Revision Lumbar Fusion
Minimally invasive spine	MILD Procedure · Interspinous Spacer · Vertiflex Superion · Percutaneous Image-Guided Lumbar Decompression
Vertebral augmentation and ablation	Kyphoplasty · Vertebroplasty · Basivertebral Nerve Ablation
Facet joint interventions	Diagnostic and therapeutic facet interventions by spinal region
Epidural steroid injections	Caudal · Cervical Interlaminar · Thoracic Interlaminar · Lumbar Interlaminar · Cervical Transforaminal · Thoracic Transforaminal · Lumbar Transforaminal · Sacral Transforaminal
Neuromodulation	Spinal Cord Stimulator Trial · Permanent Spinal Cord Stimulator · Dorsal Root Ganglion Stimulation · Peripheral Nerve Stimulator Trial · Permanent Peripheral Nerve Stimulator · Intrathecal Pain Pump Trial · Permanent Intrathecal Pain Pump · Pain Pump Replacement · Neuromodulation Prior Authorization Process Guide
Peripheral and sympathetic nerve procedures	Genicular Nerve Block · Genicular Nerve Radiofrequency Ablation · Occipital Nerve Block · Occipital Nerve Radiofrequency Ablation · Cluneal Nerve Block · Pudendal Nerve Block · Intercostal Nerve Block
Ambulatory surgery center operations	ASC Prior Authorization · ASC Documentation Requirements · Implant Authorization · Medical Device Coverage · Same-Day Surgery Documentation · Site of Service and Patient Status · Medicare ASC Billing
Diagnostics and durable medical equipment	MRI Diagnostic Imaging · DMEPOS and Spinal Orthoses, each with a Foundations Training Tier companion

GoHealthcare Knowledge Center: https://www.gohealthcarellc.com

Recommended downloads

• Orthopedic Prior Authorization Documentation Checklist (one page, printable)
• Conservative Care Ledger template (one page, printable)
• Payer and Delegated Vendor Matrix template (spreadsheet)
• Pre-Surgical Huddle Reconciliation Log (one page, printable)
• Site-of-Service Determination Worksheet (one page, printable)

• WISeR Model Companion Reference (separately versioned, refreshed against CMS publications)
• Orthopedic Denial Root-Cause Taxonomy (one page)
• Artificial Intelligence Governance Framework for MSK Practices (checklist)

Reading recommendations

• CMS CY 2026 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule and accompanying fact sheet
• CMS CY 2026 Medicare Physician Fee Schedule Final Rule and Quality Payment Program provisions
• CMS WISeR Model Provider and Supplier Operational Guide, current version
• CMS Transforming Episode Accountability Model overview and frequently asked questions
• CMS Ambulatory Specialty Model model page and the CY 2026 Physician Fee Schedule final rule provisions establishing it
• CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet
• Carelon Medical Benefits Management current musculoskeletal clinical appropriateness guidelines
• eviCore by Evernorth Comprehensive Musculoskeletal Management clinical guidelines
• American Academy of Orthopaedic Surgeons clinical practice guidelines and appropriate use criteria
• North American Spine Society coverage recommendations and clinical guidelines
• HHS Office of Inspector General General Compliance Program Guidance and the Medicare Advantage Industry Segment-Specific Compliance Program Guidance

Frequently Asked Questions

The answers below are operational guidance and are not coverage determinations. Verify payer-specific positions against the current applicable policy.

If a procedure was added to the ASC covered procedures list, can we schedule it?

Only after three separate confirmations. First, that the procedure is on the current calendar year list, verified against the CMS addenda. Second, that the specific payer's contract recognizes the procedure in the ambulatory surgery center place of service, since a commercial payer is not bound by the Medicare list. Third, that the case clears contribution margin after implant and device cost.

What changed in CPT 2026 for orthopedics?

Core arthroplasty, arthroscopy, fracture care, and evaluation and management families were largely stable. Targeted changes include an editorial revision affecting sacroiliac joint arthrodesis reporting, two limb-lengthening reconstruction codes, an add-on code for annular defect repair with a bone-anchored closure device, and a code for percutaneous balloon decompression of the median nerve. Verify every descriptor against the AMA CPT 2026 professional edition before use.

Does a new CPT code mean the service is covered?

No. A code is a reporting mechanism, not a coverage determination. Category III codes in particular are frequently non-covered. Screen every new code against the specific payer's policy before the service is offered to patients.

Authoritative References

Coverage policies, code sets, model parameters, and utilization management criteria change. Verify currency at the time of use.

• GoHealthcare Procedure Library: https://www.gohealthcarellc.com/procedure-library.html
• American Academy of Orthopaedic Surgeons: https://www.aaos.org
• North American Spine Society: https://www.spine.org
• American Medical Association CPT Resources: https://www.ama-assn.org/practice-management/cpt

Related Orthopedic Pages

Orthopedic Surgery Specialty Guide

Executive entry point for orthopedic service-line operations and the complete Orthopedic Surgery Specialty Hub.

Open this page →

Orthopedic Prior Authorization

Decision pathways, payer criteria, authorization workflow, peer-to-peer, and appeals.

Open this page →

Orthopedic Coding and Billing Fundamentals

CPT families, diagnosis coding, modifiers, place of service, and coding risk.

Open this page →

Strengthen Orthopedic Operations

GoHealthcare Practice Solutions supports orthopedic and musculoskeletal organizations with prior authorization, medical necessity, payer intelligence, documentation improvement, revenue cycle performance, compliance, and workflow design.

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Developed by GoHealthcare Practice Solutions under the leadership of Pinky Maniri, Founder and Chief Executive Officer. This page is part of the GoHealthcare Orthopedic Surgery Specialty Center and the GoHealthcare MSK Specialty Procedure Library™.

Educational and operational reference only. This content does not replace physician clinical judgment, official payer policy, current CMS guidance, the current official code sets, qualified coding review, contractual review, or legal counsel. Coverage, authorization, coding, and reimbursement requirements must be independently verified before use.