Billing and Coding: Major Joint Replacement (Hip and Knee)

Coverage for major joint replacement (hip and knee) requires documentation of advanced joint disease with radiographic evidence, pain or functional disability interfering with ADLs, and unsuccessful conservative therapy (generally ≥3 months) when applicable. Additional covered indications include malignancy, fracture, and infection-related revision when supported by appropriate pathology, imaging, lab reports, and physician notes; bilateral procedures require documentation of bilateral medical necessity and appropriate billing modifiers (50/62/RT/LT). All records must be legible, include patient identifiers and provider signature, and support the selected ICD-10-CM and CPT/HCPCS codes; non-covered services must not be billed as covered.

"Total hip arthroplasty (THA) or total knee arthroplasty (TKA) is covered for advanced joint disease when arthritis of the hip or knee is supported by X-ray or MRI demonstrating subchondral cysts, s..."