Christine Banks, RHIA, CPC, CPCO, senior healthcare consultant at KZA, discussed new Current Procedural Terminology codes, policy changes, and reimbursement guidelines that impact orthopaedic surgeons.
Published 6/26/2025
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Josh Baxt
Coding is a complex topic and quite often a moving target. To clarify some recent changes, Christine Banks, RHIA, CPC, CPCO, senior healthcare consultant at KZA, took to the stage at the AAOS 2025 Annual Meeting for Instructional Course Lecture (ICL) 292: “2025 Coding and Reimbursement Updates.” She discussed new Current Procedural Terminology (CPT) codes, policy changes, and reimbursement guidelines that impact orthopaedic surgeons.
Updates in telehealth
Ms. Banks opened with new guidelines for telehealth visits, which surged during the COVID-19 pandemic. The Centers for Medicare & Medicaid Services (CMS) relaxed its telehealth reimbursement rules for the crisis but was set to change them on Jan. 1, 2025. Those changes were delayed until April 1. Under the new rules, telehealth will only be covered by Medicare for patients in rural areas or at designated sites. By definition, telehealth services are synchronous interactive encounters between a physician or other qualified healthcare professional and a patient using combined audio/video or audio-only telecommunications.
“The telehealth rules we have had for the last 5 years, as of April 1, are reverting to what they were before, which means Medicare is not going to recognize these codes at all,” Ms. Banks explained.
Meanwhile, the American Medical Association (AMA) has developed new telehealth CPT codes in 2025, with actual coverage based on an individual payer’s policies. The new AMA codes, starting with 98000, are for synchronous audio/visual evaluation and management services. The range of codes is based on new patients or established patients, as well as either time or medical decision making.
“These are for those telehealth visits where the patient is either brand new to you or they’re established,” Ms. Banks said. “You’ve seen them in the office, and maybe they don’t necessarily need to come in again, but they need an extra visit. [Or] this patient was in the office, and now you’re going to relay some lab or x-ray information to them.”
Overall, these updates highlight a mixed trajectory for telehealth. The AMA’s new codes bring clarity and granularity to telehealth billing. CMS’ decision to revert to early reporting standards for telehealth services under Medicare limits these codes’ full potential. Providers must stay updated on the evolving regulatory environment and adapt their documentation and billing practices accordingly.
Fracture care
Ms. Banks noted that billing for fracture care is a source of confusion for many orthopaedic practices. In particular, there are many questions about closed treatments.
In one scenario, a patient comes to the office or the emergency department and does not need to be treated surgically. They receive a cast or splint and go home. The physician bills the global code. However, during an office follow-up, the radiographs show the fracture has displaced. Dissatisfied with the alignment, the surgeon decides to take the patient to the OR. Can they bill that procedure separately? The answer is yes. During the first encounter with the patient, the physician expected it to be stable and was satisfied with the alignment.
“You can bill that global code, and when they come back in again, you can bill for taking them to the OR,” Ms. Banks clarified. “You’ll put a modifier on there (modifier 58), which means it’s either a staged or more extensive procedure. In this case, it’s a more extensive procedure. It wasn’t planned, but it’s more extensive.”
Surgeons often ask if it is better to use itemized or global billing. Ms. Banks believes it depends on how many times the physician is going to see the patient. If it is only two or three times, it makes sense to bill global. If the physician sees the patient four or five times, it might be more beneficial to itemize, according to Ms. Banks.
On a slightly more granular level, choosing the itemized billing code does not impose a time limit or requirement on future billing. The global code has a 90-day period. By choosing to bill globally, a provider is locked into that global period. Every time they see that patient, unless there has been some change, they are locked into billing that patient with that global code.
“Are there times that it may go past the global period? There may, and I would document that the patient has been stable, but they’ve come back in,” Ms. Banks said. “You’ve treated them globally, they were fine, and maybe all of a sudden it’s now 4 months out, you’re talking 100 days out from that first global, and now they’re dealing with some pain.”
Being the squeaky wheel
Ms. Banks discussed the coding nuances in a variety of areas, including postoperative care and injections. But she also noted that physicians should be more willing to appeal rejected claims.
“The insurance companies like to make you jump through hoops to get paid, and they’re looking for ways to deny that claim … and expecting you not to appeal it,” Ms. Banks said. “When you think about all of those denials, and only 19 percent of those are actually appealed—that’s what the insurance companies are looking for. But out of that 19 percent that are appealed, 94 percent of those are paid.”
To learn more about CPT changes in 2025, read the article “CPT Updates 2025: New and Revised Codes for Musculoskeletal and Telemedicine Services” in the January 2025 issue of AAOS Now. A recording of the AAOS webinar “CPT, CMS 2025 Updates” is also available to view online. Visit learn.aaos.org to access the webinar catalog.
Josh Baxt is a freelance writer for AAOS Now.