Billing and Coding: Total Joint Arthroplasty

Total knee and hip arthroplasty are covered when advanced joint disease of the knee or hip is documented by X-ray or MRI with specified findings, and when pain or functional disability affecting ADLs is present; coverage generally requires unsuccessful conservative therapy (typically ≥3 months) unless conservative care is inappropriate (e.g., bone-on-bone, severe deformity or rest pain). Documentation must be legible, include provider signature, support ICD-10/CPT coding, show imaging and conservative-therapy details, address risk/benefit for comorbid patients, and include labs/pathology when infection is the indication; bilateral and co-surgeon billing require proper modifiers (-50, -62, RT/LT) and bilateral procedures are subject to bilateral pricing. Services not covered by the applicable LCD must not be billed as covered unless the treating physician documents a clear clinical justification and episode-of-care rationale.

"Total knee or hip arthroplasty is indicated for advanced joint disease (knee or hip arthritis) supported by X-ray or MRI demonstrating subchondral cysts, subchondral sclerosis, periarticular osteop..."