2026 Orthopedic Billing Strategies: Site of Service, Revenue, and Leakage Prevention

For orthopedic practices, 2026 is not just another update year. It is a reset.
Decisions about where care is delivered have always mattered clinically. Now they matter financially just as much. Medicare payment policy has made site of service a direct driver of reimbursement, and practices that do not adapt will feel it in quieter but very real ways.

If your group delivers care across physician offices, ambulatory surgery centers, and hospital outpatient departments, billing accuracy in 2026 depends on tighter alignment between scheduling, authorization, documentation, and claims.

What Is Actually Changing in 2026

Centers for Medicare & Medicaid Services is not rolling out sweeping CPT changes for orthopedics this year. The shift is more subtle and more impactful.

Across the Physician Fee Schedule, OPPS, and ASC updates, CMS continues to push the same message.

• Payment should reflect the cost of the care setting
  
• Patients should not pay more for the same service just because of where it is performed
  
• More outpatient care should move to lower-cost settings when clinically appropriate
  
  

This is what site-neutral payment looks like in practice. It is no longer theoretical. It is showing up in reimbursement data.

Why Site of Service Now Affects Revenue More Than Ever

In 2026, CMS expands site-neutral payment rules for off-campus provider-based departments. The result is rarely a denial. Instead, practices often see lower reimbursement than expected.

This usually happens when:

• The site of service is not validated before the visit
  
• Authorization is issued for one setting but care happens in another
  
• Documentation does not fully support the billed location
  
  

When the scheduled, authorized, documented, and billed site of service do not match, revenue drops quietly.

The Inpatient Only List Is Shrinking Again

CMS continues to remove procedures from the Inpatient Only list, including hundreds of musculoskeletal codes. For orthopedics, this opens the door to more outpatient billing but also creates new complexity.

What practices are seeing:

• More procedures allowed in outpatient settings
  
• Different coverage rules depending on the payer
  
• Less room for error in pre-service validation
  
  

Outpatient migration is accelerating, but billing rules have not gotten simpler.

ASCs Offer Opportunity With Strings Attached

The ASC Covered Procedures List continues to expand, making ASCs financially appealing for orthopedic care. That upside disappears quickly if workflows are not aligned.

To get paid correctly:

• Authorizations must reflect the actual care setting
  
• Documentation must clearly support outpatient medical necessity
  
• Billing must stay consistent from scheduling through claim submission
  
  

Medical Group Management Association data shows that site-of-service mismatches are one of the most common reasons for delayed or reduced payments in multi-setting orthopedic practices.

Practice Expense Changes Add Another Layer

CMS has adjusted how indirect practice expenses are calculated. That means the same CPT code can pay differently depending on whether it is performed in an office or a facility.

Hybrid orthopedic practices feel this the most. They need:

• Clear visibility into setting-based reimbursement differences
  
• Better forecasting tied to site of service
  
• Strong coordination between clinical teams and billing staff
  
  

The Real Risk Is Quiet Revenue Loss

Most orthopedic practices will not see a wave of denials in 2026. The bigger problem is revenue erosion that happens slowly and often goes unnoticed.

This shows up when:

• The billed site does not match the authorized or documented site
  
• Coding is technically correct but paid at a lower rate
  
• Post-payment adjustments increase audit or compliance exposure
  
  

Revenue integrity now depends on alignment at every step, not just clean claims.

What Orthopedic Practices Are Doing to Protect Revenue

Practices that are staying ahead in 2026 are focusing on fundamentals:

• Validating site of service before the visit
  
• Applying payer-specific authorization rules
  
• Connecting clinical, scheduling, and billing workflows
  
• Using technology that flags mismatches early
  
  

ADS helps orthopedic practices align site-of-service intelligence, payer rules, and revenue cycle workflows so underpayments are identified before they occur.

➡️ Protect your orthopedic revenue in 2026.

Common Questions About Orthopedic Billing in 2026

Why does site of service matter so much now?
CMS has expanded site-neutral payment policies. Reimbursement depends on where care is delivered, and misalignment across authorization, documentation, and billing leads to underpayment.

What is the biggest financial risk in 2026?
Quiet revenue leakage. Most losses come from underpayments rather than denials, and they are easy to miss without the right controls.

How can practices reduce revenue leakage?
By validating site of service up front, aligning authorizations to care settings, and ensuring documentation and billing follow payer-specific site rules.