G0289, Arthroscopy, knee, surgical, for removal of loose body, foreign body,
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
1.44
Facility
$72.81
Non-Facility
$72.81
Documentation Required
- Medicare contractors may require operative notes, reports of standing x-rays, and/or arthroscopy results to define the patient’s knee condition when adjudicating coverage.
- For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
- A valid ICD-10-CM diagnosis code that best describes the patient's condition must be submitted on the claim; claims without a valid ICD-10-CM code will be returned as incomplete under Section 1833(e).
- An Advance Beneficiary Notice of Noncoverage (ABN) may be used for outpatient services likely to be non-covered; follow CMS Claims Processing Manual Chapter 30 guidance when issuing ABNs.
Key Coverage Criteria
- Arthroscopic lavage or arthroscopic debridement for osteoarthritic knee in patients WITHOUT severe osteoarthritis who present with mechanical symptoms (eg, locking, snapping, popping), abnormal limb/knee alignment, or less severe/early degenerative arthritis may be considered for coverage at the discretion of the Medicare contractor.
- Arthroscopic debridement (with or without partial meniscectomy) for persons presenting with mild-to-moderate (Outerbridge classification I and II, not III or IV) osteoarthritis (OA) with knee pain plus mechanical symptoms due to loose bodies and/or meniscal tears;
- Arthroscopic partial meniscectomy for traumatic meniscal tears unless there is moderate or severe osteoarthritis present (Outerbridge classification III or IV);
- Intra-articular glucocorticoid injections for the treatment of knee OA.
- CPT/HCPCS/ICD-10 codes listed as "covered if selection criteria are met": e.g., CPT 29874 (Arthroscopy, knee, surgical; for removal of loose body or foreign body), G0289, CPTs 29880/29881 for arthroscopic partial meniscectomy, ICD-10 M17.0–M17.9 (Osteoarthritis of knee), M23.000–M23.369 (Derangement of meniscus due to old tear or injury), M25.561–M25.569 (Pain in knee), M25.661–M25.669 (Stiffness of knee), Q68.6 (Discoid meniscus) — when the CPB selection criteria are met.
- Moderate-to-severe knee pain with radiographically confirmed knee OA (Kellgren-Lawrence (KL) grade II/III).
4 Active Policies
A52369, Billing and Coding: Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee Medical Policy Article
J6
AETNA-CPB-0673, Knee Arthroscopy / Osteoarthritis of the Knee
CARELON-joint-surgery-2024-11-17-updated-2025-01-01, Joint Surgery
CARELON-joint-surgery-2025-11-15, Joint Surgery
Related Codes
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