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CPT Code 27130 | Description, Guidelines, Reimbursement, Modifiers & Examples

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 reimbursement 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 reimbursement can avoid whenever feasible.

Reimbursement

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 reimbursement 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.

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