27138
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
23.11
Facility
$1367.10
Non-Facility
$1367.10
Documentation Required
- Claims and coding must follow and reference the Local Coverage Determination L33456; consult L33456 for specific clinical coverage criteria and required documentation.
- All documentation must be maintained in the patient’s medical record and made available to the contractor upon request.
- Every page of the medical record must be legible and include appropriate patient identification information such as complete name and dates of service.
- The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the patient’s care.
Key Coverage Criteria
- Coverage for lower extremity major joint replacement (hip and knee) is subject to the reasonable and necessary requirements of Local Coverage Determination L36007; services meeting LCD L36007 criteria are covered.
- Total knee arthroplasty (TKA) or total hip arthroplasty (THA) is indicated for advanced joint disease when X-ray or MRI demonstrates subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis, or bone-on-bone articulation.
- Documented significant pain or functional disability that interferes with activities of daily living (ADLs), worsens with activity or weight bearing, supporting the need for arthroplasty.
- Unsuccessful non-surgical medical management as documented in the record, typically including one or more of anti-inflammatory medications/analgesics, flexibility and strengthening exercises, supervised physical therapy, assistive device use, reasonable activity restrictions, weight reduction when appropriate, or therapeutic intra-articular injections.
- Non-surgical management may be considered inappropriate and arthroplasty indicated when one or more of the following exist: bone-on-bone articulation, severe deformity, or severe pain (particularly at rest) causing significant disabling interference with ADLs.
- Revision TKA or THA for infection is indicated when laboratory and/or pathology reports and documentation of infection treatment are present and a physician documents that proceeding with surgery is appropriate.
19 Active Policies
A59811 — Billing and Coding: Total Joint Arthroplasty
J05
L39911 — Total Joint Arthroplasty
J05
L36039 — Total Joint Arthroplasty
J06
A57428 — Billing and Coding: Total Joint Arthroplasty
J06
A57765 — Billing and Coding: Major Joint Replacement (Hip and Knee)
Related Codes
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