AI revenue integrity for orthopedic practices

Surgical bundling errors and DME failures cost ortho practices recoverable revenue every day.

Orthopedic procedures involve some of the most complex coding in medicine, multi-procedure reductions, implant billing, DME workflows, and modifier-heavy surgical codes. Manual billing teams catch a fraction of the errors. Ember catches all of them.

Book an orthopedics demoSee the denial patterns
57%denial rate reduction
100%encounters reviewed
3 daysto first results

Trusted by specialty groups and health systems

Ozark OrthopaedicsFinancial District Foot & Ankle CenterPeninsula Gastroenterology Medical GroupMVPQuantum RadiologyMoami Hand Center

Where orthopedics revenue leaks

The denial patterns Ember was built for

Orthopedic practices face a recurring set of high-value, high-denial claim types. Surgical bundling alone can represent millions in systematic underpayment. Ember closes each gap.

01 · Surgical bundling

Multi-procedure reductions and add-on code disputes on complex surgical cases.

When multiple procedures are performed in the same operative session, payers apply multi-procedure payment reduction rules that are frequently applied incorrectly. Add-on codes are bundled inappropriately, and bilateral modifiers are disputed. Ember validates every surgical claim against each payer's specific bundling rules before submission.

27447 · 27130 · 29881 · 29827

02 · DME and implant billing

Claim failures on braces, splints, and surgical implants.

DME claims require specific HCPCS coding, documentation of medical necessity, and correct modifier application, and rules differ by payer. Surgical implant pass-through billing carries additional complexity. Ember validates every DME and implant claim before submission and works every denial systematically.

L1830 · L1832 · L4350 · A4570

03 · Joint replacement documentation

Medical necessity denials on total knee and hip replacement.

Payers apply conservative medical necessity criteria to joint replacement, requiring documentation of conservative treatment failure, functional limitation, and BMI compliance. Documentation gaps trigger denials on high-value claims. Ember flags documentation gaps before surgery and builds the appeal package when denials occur.

27447 · 27130 · 27236 · 27245

Three engines.
One source of truth.

Ember connects clinical documentation, payer policy, and contract terms into a single intelligence layer. Built for the surgical complexity and implant billing orthopedics requires.

01 · Foundation

Data Engine

Bridges the clinical and the financial. Unifies documentation, coding decisions, payer policy, and contracts across every encounter and provider.

D. Castellano

Encounter #O-33915

Unified
Documentation
Total knee arthroplasty — RT
Coding
27447M17.11RTL8699
Payer policy
Aetna · Joint replacement
Contract
Rate §6.1

02 · Audit

Coding Engine

Reviews 100% of encounters against national standards, payer-specific policies, your internal guidelines, and your payer contracts. Every flag carries a rule citation.

Audit#O-33915
29881Arthroscopy, meniscectomy
Pass
29827Add-on missing modifier 59
Flag

Append modifier 59 — distinct procedural service

CMS NCCI PTP · confidence 0.96

03 · Recovery

Appeal Engine

Reads CARC and RARC codes, identifies the applicable LCD/NCD policy and contract terms, drafts the appeal letter, packages documentation, and tracks every claim to adjudication.

Re: Claim #O-33915 · Denial CO-50

The total knee arthroplasty meets medical-necessity criteria under LCD L36577 with documented conservative-care failure, per contract §6.1…

Denial received
Appeal drafted
Submitted · in review
Adjudication pending

Audit upstream.
Appeal downstream.

Two workflows do most of the work for orthopedic practices. The first prevents denials before they happen. The second recovers the ones that slip through.

Pre-bill audit

Catch the surgical bundling issue before the claim leaves.

Ember reviews every encounter against coding standards, payer surgical policy, and your contracts. Bundling errors, DME documentation gaps, and joint replacement medical-necessity issues are flagged before submission.

  • 1

    Ingest the encounter

    Pulls operative reports, procedure codes, and implant documentation from your EHR and surgical scheduling system.

  • 2

    Validate against rules

    Checks multi-procedure reduction rules, add-on code bundling, DME documentation requirements, and implant billing against each payer's specific policies.

  • 3

    Recommend with citation

    Returns the suggested correction tied to the exact payer policy, NCCI edit, or contract term.

  • 4

    Educate the provider

    Coding patterns drive provider-level coaching, so operative note documentation and implant billing accuracy improve across every surgeon.

Encounter review#O-33915
29881Arthroscopy, meniscectomy
Pass
L8699Implant, pass-through
Pass
29827Add-on missing modifier 59
Flag

Append modifier 59 — distinct procedural service

CMS NCCI PTP · confidence 0.97

+23%

Clean-claim rate

100%

Encounters reviewed

+5%

Net collection rate

Automated appeals

Pull. Review. Push.

When a denial occurs, Ember identifies the root cause, retrieves operative reports, implant invoices, and conservative-care records, references payer policy and contract terms, drafts the appeal, and tracks it through adjudication.

Pull12
CO-50

Medical necessity

CO-16

Missing modifier

Review7
CO-97

Bundling reduction

Push9
CO-B15

DME documentation

Learn—
PAID

Joint replacement appeal

-57%

Denial rate

-45%

Cost to collect

+9.3%

Net revenue per appt

The full revenue cycle

From eligibility to adjudication. Covered.

Audit and appeals are the workhorses, but Ember protects orthopedic revenue at every stage of the cycle.

Eligibility Verification

Confirms active coverage and surgical benefit structure before the case, and flags implant coverage gaps before they become billing problems.

Prior Authorization

Checks auth requirements in real time for joint replacement and complex surgical procedures, generates medical-necessity documentation, and submits to payer portals automatically.

AI Medical Coding

Reviews 100% of encounters, surgical codes, DME charges, and implant billing, against national standards and payer rules before claims submit.

Pre-bill Audit

Predicts and prevents denials before claims go out, catching multi-procedure bundling errors, DME documentation gaps, and medical-necessity issues before they generate write-offs.

Denial Management

Full appeal lifecycle for every ortho denial type, bundling dispute, DME failure, medical necessity, and modifier error, tracked to adjudication.

Underpayment Recovery

Parses contracts to model what each surgical and implant claim should pay, then surfaces line-item underpayments at scale.

High-value surgical revenue, recovered

-57%

denial rate

-45%

cost to collect

100%

encounters audited

3 days

to first results

Based on Ember AI benchmarks across customer practices. Results vary by payer mix and specialty.

Frequently asked questions

Everything you need to know about how Ember fits into your revenue cycle.

Yes. Ember AI connects seamlessly with all major EHRs and PMS platforms, including Epic, Oracle Cerner, athenahealth, and eClinicalWorks, as well as payer portals. Our standards-based integrations automate prior authorization, eligibility verification, and claims submission, allowing you to preserve existing infrastructure while modernizing the revenue cycle.
Ember AI deployments are measured in weeks, not months. Most organizations complete pilot launch in under 30 days and scale enterprise-wide within a quarter. We provide a structured onboarding playbook, technical support, and change-management guidance so your teams achieve measurable ROI rapidly with minimal IT lift.
Yes. Ember AI is fully HIPAA and SOC 2 Type II compliant and signs Business Associate Agreements (BAAs) with all covered entities. Protected Health Information (PHI) is encrypted in transit and at rest, supported by role-based access controls, detailed audit logging, and continuous monitoring. Your organization retains complete ownership and control of its data.
Health systems, MSOs, and health plans using Ember AI typically achieve:

- 50-75% reduction in FTE hours
- Faster cash acceleration
- Prevent 55%+ of denials

We provide ROI benchmarks and dashboards so you can track outcomes from day one.
Yes. Ember's coding and scrubbing logic is specialty-aware, it understands orthopedic procedures, surgical bundling, global periods, implants, and modifier and laterality (RT/LT, 25, 59, 51) requirements, and validates documentation against payer medical-necessity criteria before submission.
Yes. Ember checks eligibility, identifies which surgeries, implants, and advanced imaging require pre-auth, gathers the needed documentation from your EHR, and submits through payer portals, reducing the scheduling delays and missing-auth denials that hit high-value orthopedic cases.
Ember tracks the 10- and 90-day global window on every procedure and flags post-op, staged, and unrelated services that need a modifier, while validating modifiers 25, 59, 51 and RT/LT/bilateral indicators against the operative note, preventing the bundling and modifier denials orthopedics sees most.
Yes. Ember's charge capture keeps implant logs, HCPCS codes, invoices, and DME documentation complete on every surgical case, so high-dollar hardware is billed correctly the first time and revenue doesn't leak.
Ember connects to your existing EHR/PMS and payer systems with standards-based integrations, no rip-and-replace. Most teams pilot in days and see measurable ROI before scaling across service lines.

See what your ortho practice is leaving on the table

Bring us 30 days of denial data. We'll show you where the revenue is and exactly how Ember would recover it.

Book an orthopedics demoBack to Ember