Orthopedic Practices Alert: Major CMS Updates, Prior Auth & Code Risks in 2026

The orthopedic billing landscape is undergoing major changes in 2025, and practices must adapt quickly to protect revenue. CMS has introduced new billing rules, evolving E/M documentation standards, and revised ICD-10 and CPT codes impacting common orthopedic procedures, injections, imaging, and fracture care.
Prior authorization rules are also tightening under CMS’s new “Gold Card” program, which grants exemption only to consistently compliant providers. Meanwhile, payer-specific policy changes are increasing medical necessity audits, bundling rules, and stricter orthopedic reimbursement edits.
Automation and AI-driven RCM tools are becoming crucial for orthopedic groups to streamline eligibility checks, code validation, pre-auth workflows, and denial prevention. Outsourcing orthopedic billing to specialty-focused RCM teams is emerging as a strategy to reduce AR days and improve clean claim rates.
Overall, 2025 demands tighter compliance, better technology adoption, and expert-level coding precision to maintain financial stability in orthopedic practices. Read full blog here.

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