The 2026 Medicare Physician Fee Schedule finalized changes that affect surgical reimbursement across musculoskeletal procedures. The general pattern continues: CMS adjusting conversion factors for certain high-volume procedures while expanding reimbursement for evaluation and management codes and remote monitoring services.
E/M documentation: are you capturing what you should?
The 2021 through 2023 E/M recodification that simplified documentation requirements and boosted E/M reimbursement is fully embedded in billing practice. But many orthopaedic practices are still underutilizing the higher-level codes they legitimately qualify for.
Medical decision making complexity now drives E/M level selection. For orthopaedic practices, this means documenting:
- The complexity of problems addressed (single acute problem vs. multiple chronic conditions vs. exacerbation of a known condition)
- Data reviewed (external records, tests ordered, independent interpretation of imaging)
- Risk of treatment decisions (whether major elective surgery was recommended)
A complex orthopaedic visit — reviewing MRI, discussing surgical options, counseling a patient through conservative alternatives — typically supports high MDM and a 99215. Many practices default to 99214 for established patients when the visit supports more. An audit of your last 90 days of E/M coding is worth doing at least annually.
Outpatient total joint replacement
CMS has continued expanding the list of joint replacement procedures available in ambulatory surgical centers. For practices with ASC relationships or ownership, the site-of-service differential is significant. The Medicare reimbursement difference between hospital outpatient and ASC for total knee arthroplasty is meaningful, but ASC ownership carries compliance obligations that should be reviewed with a healthcare attorney.
For practices in CJR (Comprehensive Care for Joint Replacement) markets, 90-day episode cost benchmarks update annually. Review your episode costs quarterly and identify the post-acute care partners who are driving outlier costs.
Remote therapeutic monitoring
RTM codes (98975, 98976, 98977, 98980, 98981) allow billing for monitoring therapy adherence and clinical response via digital platforms. For orthopaedic practices with post-surgical patients using digital rehab apps or wearable monitoring, these codes represent incremental revenue that most practices are not capturing.
The billing requirements: 20 or more days of monitoring data in a calendar month for the data collection codes; the clinical management codes require a physician or NPP to provide minimum service time. Most major EHR systems now support RTM billing tracking.
If your practice uses any remote rehab platform — MedBridge HEP, Hinge Health, or similar — review whether you are billing the associated monitoring codes. The gap between practices that have implemented RTM billing and those that haven't is significant.
Prior authorization: electronic submission
The interoperability and prior authorization rules that took effect in 2026 require health plans to respond to PA requests within 72 hours for urgent cases and 7 days for standard requests, using standardized electronic APIs. This applies to Medicare Advantage, Medicaid managed care, and marketplace plans.
For orthopaedic practices, this means some payers now accept electronic prior auth submissions directly through your practice management system. Manual phone-based PA workflows should be declining as payer systems update — verify with your major payers whether electronic submission is available. The time savings are real, and electronic submission creates a cleaner paper trail for denials management.
Telehealth
CMS extended temporary telehealth flexibilities through 2026. Audio-visual telehealth visits remain billable at the same rate as in-person visits under the current extension.
For orthopaedic practices, telehealth is most efficient for post-operative follow-ups at 2 and 6 weeks (reviewing wound photos, addressing patient questions), pre-surgical consultations for established patients, and care coordination calls with referring PCPs.
Documentation requirements are the same as in-person visits. Confirm that your EHR records the telehealth modifier (-95 for synchronous audio-video) consistently.