As the third-highest opioid-prescribing medical specialty representing 6 to 8 percent of all U.S. opioid prescriptions, orthopedic surgeons carry an outsized share of responsibility for reducing patients’ opioid exposure. Orthopedic procedures dominate this pattern as they represent four of the five surgeries with the highest opioid prescription rates among patients aged 45 to 64. Even more alarming, orthopedic surgeons often treat young and active patients, and for many, surgery represents their first exposure to opioid medications. That single exposure carries a 2 to 5 percent risk of continued use even when it is prescribed for acute pain, which gives our field both a responsibility and an opportunity to lead and places us in a critical position to influence prescribing practices and expectations surrounding pain management.
Furthermore, more complex cases are migrating to outpatient settings and ambulatory surgery centers (ASCs), so patients are managing more of their recovery at home. It is crucial that we appropriately manage patients’ postoperative pain without increasing the risk of adverse events or complications. For years, clinical evidence has shown that cold therapy is effective in helping manage acute postoperative pain. One of the primary barriers to its utilization was reimbursement, not evidence that it was the right thing. Cold therapy devices were bundled into the procedure payment, leaving facilities to absorb the cost.
The NOPAIN Act has changed that. As of January 1, 2026, continuous cold therapy is eligible for separate Medicare facility payment in hospital outpatient departments (HOPDs) and ASCs. That change was years in the making, and it corrects a problem that was never clinical. The evidence for these approaches was already there, but the outpatient payment system hadn’t kept pace.
The NOPAIN Act removes a cost barrier, not an evidence gap
Under the NOPAIN Act, Medicare now makes a separate facility payment for CMS-designated non-opioid therapies used in outpatient surgery, pulling proven options like cold therapy out of the bundled procedure payment and onto their own line. It’s billed under HCPCS code C9810.
Real physician voices, twice a week
Free, and one click to unsubscribe.
To qualify, a therapy must demonstrate with peer-reviewed data that it can reduce, replace, or avoid opioid use. The standard is clinical evidence, which cold therapy has long met. Currently, IceMan by Enovis is the only single-patient continuous cold therapy eligible for Medicare reimbursement under the NOPAIN Act. Separate payment provisions currently run through 2027, so this isn’t yet a permanent fixture, and it will take continued advocacy to extend it.
For those of us in practice, the change is refreshing. I used to tell patients that a cold therapy unit was an out-of-pocket expense of a couple hundred dollars, and those on a fixed income would either skip it or buy a used device. Now I can send every Medicare-eligible patient home with a unit as a standard part of recovery, rather than an upgrade they pay for out of pocket.
What clinical evidence shows
Removing the cost barrier only matters if the therapy earns its place, and cold therapy has the peer-reviewed record to support it across a range of orthopedic procedures. In arthroscopic rotator cuff repair, a standardized cold therapy regimen lowered VAS pain scores through the first postoperative week, significantly on day 2 (3.1 vs. 4.0, p=0.03), and reduced first-week opioid use by roughly 53 morphine milligram equivalents (MME), or about 10 fewer Percocet tablets per patient. In shoulder arthroplasty, patients receiving a multimodal approach including cold therapy consumed fewer opioids through 12 weeks and were far more likely to be off opioids by 2 weeks (86.1 percent vs. 58.5 percent). The benefit isn’t confined to the shoulder, either: Cryotherapy has been shown to reduce both pain and pain-medication use after other orthopedic procedures.
What makes those results resonate with surgeons is the mechanism. In arthroscopy, we push liters of fluid into a confined space, almost creating an environment similar to a temporary compartment syndrome, and the nerve blocks that get patients through the first hours eventually wear off. The swelling is still there, and this opens the door to rebound pain on postoperative days 1 and 2 when pain tends to peak. Continuous cold therapy can help reduce that swelling and blunt the rebound. And, because it delivers continuous cold with no ice packs to swap out, patients are far more likely to stay compliant and use it correctly at home.
Building it into a multimodal protocol
It is important to note that cold therapy is one key prong of a multi-pronged approach, not a standalone solution. My own protocol pairs the device with five or six non-opioid medications: an anti-inflammatory, a nerve block pain medication, a muscle relaxant, acetaminophen, and magnesium. Each medication in this protocol was selected to attack the pain pathway at its source instead of masking it the way opioids do.
The results have been hard to argue with. Most of my patients come back at one week taking little more than ibuprofen and acetaminophen, and my own opioid prescribing has dropped to roughly a tenth of what it once was. Overall, they are happy with their pain management and express the happiness of not living in a “fog” often associated with narcotic use. Generally, I have patients run the cold therapy unit on a 20-minutes-on, 20-minutes-off cycle, and many keep using it for months, including after they have started physical therapy. It becomes their “go-to” device anytime they start to experience any discomfort.
There is also a compelling economic rationale for adopting these opioid-reducing protocols. As reimbursement models increasingly incorporate quality metrics and postoperative complications, opioid-related adverse events, emergency department visits, and readmissions can carry significant financial consequences. Providing patients with a safe, effective, and easy-to-follow non-opioid pain management strategy has the potential to improve both clinical outcomes and value-based performance. For me, frankly, this is a no-brainer. Incorporating these pathways into standard discharge protocols is particularly beneficial for the predominantly fixed-income Medicare population.
None of this is new medicine. Cold therapy has reduced pain and opioid use for years, and surgeons have been incorporating it into multimodal protocols for just as long. What the NOPAIN Act changed is whether the ASC or HOPD can receive reimbursement for what we already know works. It’s important to note that for now, the NOPAIN Act is only approved through 2027. Getting here took effort, and staying here will take more. If we want this pathway to outlast its current window, the advocacy work is only just beginning. The clearest argument we can make is a track record of putting these protocols to use and continuing to demonstrate its important role in decreasing narcotic usage in postoperative patients.
Stephanie Muh is an orthopedic surgeon.
