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.