CPT code 27130 is a medical procedure for pelvic and hip joint repair, revision, and replacement. In this surgery, a prosthesis, or artificial hip joint, is surgically implanted to replace the hip joint.
The CPT code for musculoskeletal surgery is CPT 27130. Most specialists agree that this code can use to replace hip and thigh prostheses.
The costs of this procedure are detailed below. A publicly accessible database lists all providers who have submitted Medicare claims with the 27130 CPT code.
X-rays and MRIs can reveal hip or knee arthritis. The X-ray or MRI should show one or more of the following:
- subchondral cysts;
- peri-articular osteophytes;
- joint subluxation;
- joint constrictions, and
- avascular necrosis are all examples of subchondral lesions.
Functional limitations caused by hip or knee pain that worsens as an activity start is one example of functional impairment, as does the discomfort that intensifies when you bear weight. All of these are examples of functional impairment.
Documentation of a fair effort at conservative therapy requires the patient’s current episode of care (often three months or more).
Documented evidence of such treatment includes an NSAID trial, physical therapy under the direction of a doctor, or a written contraindication. Regardless of non-surgical medical treatment, evidence should demonstrate that ADLs are limited owing to pain or impairment.
Joint and hip replacements have been a tremendous stride forward in orthopedic surgery for the past few decades, benefiting millions of patients.
The large weight-bearing joint’s femoral head will divide into two halves (acetabulum). A synovial membrane forms articular cartilage, which can immerse in these joints.
Because of arthritis, it is impossible to walk, squat, or climb stairs, among other daily tasks (ADLs). After sitting for an extended period, patients typically find it challenging to move around, and their pain is often at its worst when they try to exercise.
CMS is contemplating whether to remove hip replacements from the list of operations offered only to hospitalized patients.
This suggestion will affect CPT 27125 and CPT 27130 for partial hemiarthroplasty of the hip with femoral stem prosthesis and bipolar arthroplasty and arthroplasty.
The organization is also seeking feedback on whether total knee replacements should include in the ambulatory surgery centers’ list of surgical procedures.
The RUC and we agreed that the exact valuations for the 27130 CPT code and CPT 27447 should be valued equally. Per our clarification, as advised by the specialist societies, we increased the work RVUs for these two codes from the required amount for each code to represent visits worldwide.
As a result, we assigned intermediate final work RVUs of 20.72 to CPT code 27130 and CPT code 27447. For these services, we invited public input on the appropriate RVUs and the best way to resolve the medical community’s inconsistent knowledge of time values.
27130 CPT Code Description
The CPT manual’s official description of CPT code 27130 is: “Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft.”
CPT 27130 will report by the surgeon. The technique will consider a revision arthroplasty if the patient requires antimicrobial therapy before a new component can insert.
The surgeon, for example, installs an articulating spacer after removing an infected hip prosthesis. Recovery audit and Medicare administrative contractors investigated hip and knee arthroplasty operations.
CTP code 27130: Hip arthroplasty in its entirety during arthroplasty, autograft, or allograft cannot require replacing the acetabular and proximal femoral prostheses.
CTP code 27132: After a partial hip replacement, use an autograft or allograft to accomplish a total hip replacement.
A primary arthroplasty replaces the natural joint surface or surfaces with artificial implants. For example, a patient with severe hip osteoarthritis may require a total hip replacement.
Orthopedic practitioners can avoid coding errors by precisely documenting a surgical indication and providing the operation title in each operational note.
- Include a message stating that surgery is necessary. In the initial operation letter, make a statement about any planned follow-up procedures, then document each step in detail.
- Document the medical justification for not recommending conservative therapy.
- Include any pertinent history notes from the referring doctor.
- The procedure title includes the words “revision” and “conversion.” There is no conversion CPT code for the knee.
- Take notice of the dates for the global period.
- To justify the usage of modifier 22, demonstrate that a physician’s workload, complexity, medical conditions, and time have increased. You should also be aware of Medicare’s documentation requirements for joint operations. Primary, revision, and conversion are all included.
The primary goals of total hip replacement surgery are to relieve pain and improve or increase the patient’s functionality. In rare situations, a second surgery for a total hip replacement requires.
It refers to a revision or total hip replacement. Chronic, incapacitating pain and loss of function caused by the failure of the first joint replacement necessitate a revision total hip replacement.
A common infection can cause prosthetic failure, severe bone loss in the prosthesis structures, a fracture, aseptic component loosening, or wear on the prosthetic elements.
Commentators have called for more reliable time data can include. As a result, the RVUs for this code should not fall below the figures from CY 2013, indicating that the time spent on this code has not changed since the last valuation.
Another idea was collaborating with specialty societies to research the best data collection methods. Another commenter recommended valuing these services. According to one commenter, their ratings should award differently because hip and knee replacement operations are clinically distinct.
Two respondents expressed concern about using a final regulation to compute interim values for established hip and knee operations due to stakeholders’ little time to assess and comment on reductions before implementation.
The following list(s) of procedure and diagnosis codes could be incomplete. There is no indication that the inclusion of a CTP code in this policy indicates whether or not the associated service is covered.
The contract between the member, their benefit plan, and any applicable legislation governs benefit coverage for medical services. The presence of a code does not imply a promise or entitlement to reimbursem*nt for a claim. Other policies could exist.
Billing Guidelines
A hospital paid for the entire hip replacement treatment. Due to a lack of supporting medical data, Medicare ruled the beneficiary’s procedure unnecessary. There was no pathology note to back up the medical record’s absence of information on the treatments tried before surgery.
- A preoperative x-ray or file notes reflecting the severity of hip osteoarthritis Another way to express it is
- The payment will eventually reject.
- It is critical to select the correct patient status code on the first page of claims, and if there are more than two patients.
- If you submit a claim with the incorrect code, it can reject due to a billing issue.
- Canceled and refund received.
To avoid billing problems and improper payments when two doctors with different specialties should engage. When doing the identical procedure, each surgeon must apply Modifier 58.
CPT Code 27130 & Modifier 58
Modifier 58 can be used to report CPT code 27130. Modifier 58 denotes a staged or related operation or therapy provided by the same practitioner for postoperative care.
If the doctor believes that the 27130 CPT code procedure will require more than one session, Modifier 58 should use. It is vital to remember that if the additional operation is related to the original event that triggered the global period, modifier 58 may be necessary.
If the following requirements follow for CTP code 27130, Modifier 58 can use:
“If the initial treatment did not work, the subsequent surgery could require a necessary step in the process, or you need to recommend therapy after a diagnostic surgical procedure.”
Modifier 58 will use for CTP code 27130 if a follow-up surgery occurs within the overall time range of the initial operation and the doctor anticipates a scheduled (or staged) procedure.
The 58 modifier can still use as long as the unexpected approach is more complicated and relevant to the actual operation’s aim and is more complicated. Modifier 78, which some users may mistake for another modifier, should not be used.
Patient treatment records are critical to ensuring that any difficulties will address swiftly and effectively and that delayed reimbursem*nt can avoid whenever feasible.
Reimbursem*nt
There is only one doctor, and there may be additional charges. The “Medicare permitted amount” is the amount the doctor or supplier will reimburse for the 27130 CPT code procedure.
Original Medicare typically covers 80% of this expense, with the patient liable for the remaining 20%.
Physician reimbursem*nt for all knee and hip arthroplasty surgeries reduce. Politicians, hospitals, and surgeons must consider these trends to ensure fair access to high-quality hip and knee arthroplasty care in the United States.
Example
A 78-year-old male patient has a total knee arthroplasty performed by the surgeon. During the surgery, the surgeon accesses the posterior knee by removing an old poly liner and replacing it with a new one. The surgeon will return to the operating room for an arthrotomy during the global phase.
The physician supplies CPT code 27310 for arthrotomy, knee, exploration, drainage, or foreign body removal for infection. While a different poly liner will use, this is not a revision or staged procedure. Instead, the poly liner will remove to gain access to the posterior knee.
FAQs
While modifier 51 and 59 both apply to additional procedures performed on the same date of service as the primary procedure, modifier 51 differs from modifier 59 in that it applies to procedures that may be more commonly expected to be performed during the same session.
What is included in CPT code 27130? ›
Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft.
How do you know if a CPT code needs a modifier? ›
Modifiers should be added to CPT codes when they are required to more accurately describe a procedure performed or service rendered.
What is an example of modifier 59? ›
For example, you may report modifier 59 if you perform 1 service during the initial 15 minutes of therapy and you perform the other service during the second 15 minutes of therapy.
What is the 51 modifier with example? ›
Modifier 51 is defined as multiple surgeries/procedures. Multiple surgeries performed on the same day, during the same surgical session. Diagnostic Imaging Services subject to the Multiple Procedure Payment Reduction that are provided on the same day, during the same session by the same provider.
What modifier goes first 50 or 51? ›
You should list the most resource-intense (highest paying) procedure first, and append modifier 51 to the second and subsequent procedures.
Is CPT code 27130 an inpatient only procedure? ›
Total Hip Arthroplasty and the Inpatient-Only List (IPO) CMS removed CPT code 27130 (THA) from the IPO list. As such, providers will now be reimbursed by Medicare for THA performed during a hospital outpatient stay.
What is the difference between CPT code 27130 and 27132? ›
Current Procedural Terminology (CPT) codes
For this study, CPT 27130 was used to identify primary THA, while CPT 27132 was used to identify conversion THA.
Does Medicare pay for allograft? ›
Q: Does Medicare cover placement of an amniotic tissue allograft? A: Yes, when medically necessary.
How do you know which modifier to use? ›
The correct modifier to use is determined by payor preference. There can be instances where a CPT code is further defined by a HCPCS modifier, for example, to describe the side of the body the procedure is performed on such as left (modifier -LT) or right (modifier -RT).
A medical coding modifier is two characters (letters or numbers) appended to a CPT® or HCPCS Level II code. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code.
When and where CPT modifiers are used? ›
CPT modifiers (also referred to as Level I modifiers) are used to supplement the information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician. Code modifiers help further describe a procedure code without changing its definition.
What is modifier 57 used for? ›
CPT modifier 57 may be used to report the decision for surgery for certain codes. This modifier may be used to indicate that an evaluation and management (E/M) service performed on the same day or the day before a major surgery (090 global days) by the surgeon resulted in the decision to perform the procedure.
What is modifier 50 used for? ›
Use modifier 50 to report bilateral procedures performed during the same operative session by the same physician in either separate operative areas (e.g., hands, feet, legs, arms, ears) or in the same operative area (e.g., nose, eyes, breasts).
What is a modifier 52? ›
This modifier is used to report a service or procedure that is partially reduced or eliminated at the physician's discretion. Submit CPT modifier 52 with the code for the reduced procedure. Report this modifier for discontinued radiology procedures and other procedures that do not require anesthesia.
What is a 53 modifier used for? ›
CPT modifier 53 for discontinued procedure indicates that a surgical or diagnostic procedure was started but discontinued.
What is a 56 modifier used for? ›
Modifier 56 indicates that a physician or qualified health care professional other than the surgeon performed the preoperative care and evaluation prior to surgery.
What is the 47 modifier used for? ›
Anesthesia by surgeon. Guidelines and Instructions: This modifier may be submitted when the operating surgeon performs the anesthesia service (does not include local anesthesia). Add CPT modifier 47 to the basic service for regional or general anesthesia provided by the surgeon.
Which modifier goes first 59 or TC? ›
If you code two pricing modifiers that include either a professional or technical component (26 or TC), always use the 26 or TC first, followed by the second pricing modifier. If you have two payment modifiers, for example 51 and 59, enter 59 first and 51 second.
What is the difference between 50 modifier or RT LT? ›
# of Units
When using Modifier 50 to indicate a procedure was performed bilaterally, the modifiers LT (Left) and RT (Right) should not be billed on the same service line. Modifiers LT or RT should be used to identify which one of the paired organs were operated on.
Modifier 51 is used to identify the second and subsequent procedures to third party payers. The use of modifier 51 indicates that the multiple procedure discount should be applied to the reimbursem*nt for the code.
Is 27130 on inpatient only list? ›
Separate SOS Review Required: CPT code 27130 is not included on the Medicare Inpatient Only list.
How do you bill inpatient only procedures outpatient? ›
If an "inpatient-only" procedure is performed in the outpatient setting, and the patient is subsequently admitted as an inpatient, the "inpatient-only procedure" can be reported on the inpatient claim when the services are: Provided on the date of inpatient admission. Provided within 3 days of inpatient admission.
What procedures are on the inpatient only list? ›
Medicare's Inpatient Only Surgery List
- Coronary artery bypass grafting (CABG)
- Gastric bypass surgery for obesity.
- Heart valve repair or valve replacement.
Knee arthroplasty CPT codes
- 27437 Arthroplasty, patella; without prosthesis.
- 27438 with prosthesis.
- 27440 Arthroplasty, knee, tibial plateau;
- 27441 with debridement and partial synovectomy.
- 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee;
- 27443 with debridement and partial synovectomy.
CPT® Code 73521 in section: Radiologic examination, hips, bilateral.
Is a total hip replacement on the inpatient only list? ›
Weber, MD, FAAOS, president of the American Association of Orthopaedic Surgeons, released a statement expressing the disappointment of the AAOS with the decision to remove hip replacements from the inpatient only list beginning in 2020.
What is the difference between an allograft and an autograft? ›
Autograft. A patient's own tissue - an autograft - can often be used for a surgical reconstruction procedure. Allograft tissue, taken from another person, takes longer to incorporate into the recpient's body .
Is an allograft considered an implant? ›
Definition & Overview. Biologic implants can refer to a bone, soft tissue, or skin that is harvested from a donor site and transplanted into the recipient site. Also called biological tissue, such implants can be categorised as autograft, allograft, or xenograft.
How does Medicare reimburse for transplants? ›
Medicare reimburses its share based on the ratio of Medicare usable organs to total usable organs for the specific organ type. Therefore, properly identifying Medicare and total usable organs is critical for appropriate Medicare reimbursem*nt.
Modifier 59 is one of the most used modifiers. You should only use modifier 59 if you do not have a more appropriate modifier to describe the relationship between two procedure codes. Modifier 59 identifies procedures/services that are not normally reported together.
Which modifier should go first? ›
In the case of more than one modifier, you code the “functional” modifier first, and the “informational” modifier second. The distinction between the two is simple: you always want to list the modifiers that most directly affect the reimbursem*nt process first.
What is the 27 modifier used for? ›
The CPT defines modifier –27 as “multiple outpatient hospital evaluation and management encounters on the same date.” HCFA will recognize and accept the use of modifier –27 on hospital OPPS claims effective for services on or after October 1, 2001.
What are the 5 modifiers? ›
What are the different kinds of modifiers?
- Adjective phrases.
- Adjective clauses.
- Adjectives.
- Adverbs.
- Adverbial phrases.
- Adverbial clauses.
- Limiting modifiers.
- Misplaced modifiers.
There are three access modifiers:
- public - the property or method can be accessed from everywhere. This is default.
- protected - the property or method can be accessed within the class and by classes derived from that class.
- private - the property or method can ONLY be accessed within the class.
The Modifier keys are the Shift key, the Option key and the Command key on a Mac, if you are on Windows that would be the Shift key, the Alt key and the Ctrl key. These keys are called Modifier Keys because they change the behavior of how tools usually work.
What is the PC modifier used for? ›
What you need to know. Modifier 26 is defined as the professional component (PC). The PC is outlined as a physician's service, which may include technician supervision, interpretation of results and a written report. Use modifier 26 when a physician interprets but does not perform the test.
Which modifier comes first 24 or 25? ›
Use both the 24 and 25 modifiers. Modifier 24 because the E/M service is unrelated and during the post-op period of the surgery. Modifier 25 to show the E/M is significant and separately identifiable from the procedure.
What is the 25 modifier used for? ›
Modifier 25 – this Modifier is used to report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified health care professional.
What is a 79 modifier? ›
Modifier 79 is used to indicate that the service is an unrelated procedure that was performed by the same physician during a post-operative period. Modifier 79 is a pricing modifier and should be reported in the first position. A new post-operative period begins when the unrelated procedure is billed.
CPT modifier 77 is used to report a repeat procedure by another physician. This modifier may be submitted with EKG interpretations or X-rays that require a second interpretation by another physician.
What is the 78 modifier? ›
Modifier 78 is used to report an unplanned return to the operating or procedure room, by the same physician, following an initial procedure for a related procedure during the post-operative period.
What is a 99 modifier? ›
Modifier 99 indicates multiple modifiers; under certain circ*mstances, two or more modifiers may be necessary to completely delineate a service. In such situations, modifier 99 should be added to the basic procedure and all other applicable modifiers should be listed as part of the description for the service.
What is a 58 modifier used for? ›
Modifier 58 is defined as a staged or related procedure performed during the postoperative period of the first procedure by the same physician. A new postoperative period begins when the staged procedure is billed.
Does modifier 50 affect reimbursem*nt? ›
Modifier 50 affects payment
For Medicare and many commercial payors, proper application of modifier 50 increases reimbursem*nt to 150 percent of the allowable fee schedule payment for the code to which the modifier is appended.
What is the 74 modifier? ›
Use modifier 74 for discontinued outpatient hospital/ambulatory surgical center (ASC) procedure after administration of anesthesia. This modifier is not for physician use. It is only appropriate for the ASC. For physician reporting of discontinued procedures, refer to modifier 53.
What is the 76 modifier? ›
Modifier 76 is used to report a repeat procedure or service by the same physician and is appended to the procedure to report: Repeat procedures performed on the same day. Indicate that a procedure or service was repeated subsequent to the original procedure or service.
What is the 55 modifier? ›
Modifier 55 Definition
When one physician or other qualified healthcare professional manages the post-op care and another performs the surgical procedure. The surgeon fully transfers all or a portion of the post-op care.
Under what circ*mstances would modifier 59 not be appropriate? ›
Modifier 59 should not be used on Evaluation and Management Codes, and should only be used when no other modifier is accurate. Although it does not require a different diagnosis for each coded procedure, a different diagnosis also does not necessarily justify the use of the modifier.
Is modifier 51 used anymore? ›
For instance, Medicare no longer requires modifier 51, as their internal systems are programmed to add 51 internally to the correct procedure code(s), and make the appropriate reductions to the remaining services billed.
If the operating physician requests that the anesthesia practitioner perform pain management services after the postoperative anesthesia care period terminates, the anesthesia practitioner may report it separately using modifier 59 or XU.
Does Medicare require modifier 51? ›
Medicare does not recommend reporting Modifier 51 on your claim; the processing system has hard-coded logic to append the modifier to the correct procedure code. Definition: Multiple surgeries performed on the same day, during the same surgical session.
Which modifier goes first 26 or 59? ›
Always add 26 before any other modifier. If you have two payment modifiers, a common one is 51 and 59, enter 59 in the first position.
Does modifier 59 affect reimbursem*nt? ›
Modifier 59 allows you to unbundle — separately report and get paid for — two or more procedures occurring during the same encounter by the same physician that would not normally be paid independently. Use modifier 59 correctly, and you'll collect every penny of reimbursem*nt for the work you do.
What is a modifier 53 used for? ›
CPT modifier 53 for discontinued procedure indicates that a surgical or diagnostic procedure was started but discontinued.
What is the 54 modifier used for? ›
Modifier 54
Surgical Care Only. When a physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding this modifier to the usual procedure code.
What is 63 modifier used for? ›
Modifier 63 - Procedure Performed on Infants less than 4kg
Current Procedural Terminology (CPT®) modifier 63 represents procedures performed on neonates and infants up to a present body weight of 4 kilograms.
What is a 50 modifier used for? ›
Use modifier 50 to report bilateral procedures performed during the same operative session by the same physician in either separate operative areas (e.g., hands, feet, legs, arms, ears) or in the same operative area (e.g., nose, eyes, breasts).
What is the Xu modifier used for? ›
HCPCS modifier XU indicates that a service is distinct because it does not overlap usual components of the main service. It is used to note an exception to National Correct Coding Initiative (NCCI) edits.
Does modifier 51 affect reimbursem*nt? ›
Modifier 51 is used to identify the second and subsequent procedures to third party payers. The use of modifier 51 indicates that the multiple procedure discount should be applied to the reimbursem*nt for the code.
Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circ*mstances.
