How To Bill Total Knee Replacement (TKR)

Total knee replacement, also known as total knee arthroplasty, is a surgical procedure that involves replacing damaged or worn-out knee joint parts with artificial components. This procedure is commonly performed to relieve pain and restore function in patients with severe knee arthritis or other knee joint disorders. This article will provide a detailed overview of the CPT and ICD-10 codes used for total knee replacement, Medicare guidelines, and other important considerations for billing this procedure, we include the use of modifiers and we’ll end the article with billing examples for total knee replacement procedures.

CPT Codes for Total Knee Replacement

There are several CPT codes for total knee replacement that may be used, depending on the specific procedure performed:

CPT 27447: Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty).

This code is used for total knee arthroplasty involving the medial and lateral compartments of the knee, with or without patella resurfacing. This is the most common code used for primary total knee replacement procedures. It is important to note that for revision of total knee arthroplasty, CPT 27487 should be used, and for removal of total knee prosthesis, CPT 27488 should be used.

CPT 27487: Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component.

This code is used for revision of total knee arthroplasty, which involves replacing a previously implanted artificial knee joint. This code covers the replacement of both the femoral and entire tibial components, with or without an allograft. Revisions may be necessary due to complications, wear, or loosening of the original prosthesis.

CPT 27488: Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee.

This code is used to remove a total knee prosthesis, including the methylmethacrylate (a type of bone cement), with or without the insertion of a spacer. This procedure may be performed in cases of infection, severe loosening, or other complications requiring the prosthesis’s removal.

CPT 27580: Arthrodesis, knee, any technique.

This code is used for knee arthrodesis, which involves fusing the bones of the knee joint together to provide stability and pain relief. This procedure may be an alternative to total knee replacement in certain cases, such as severe deformity or instability that cannot be corrected with a prosthesis.

ICD-10 Codes for Total Knee Replacement

There are several ICD-10-CM codes for total knee replacement that may be used, depending on the patient’s specific condition and the reason for the surgery:

  • Z96.651 – Presence of right artificial knee joint
  • Z96.652 – Presence of left artificial knee joint
  • Z96.653 – Presence of artificial knee joint, bilateral

These codes indicate the presence of an artificial knee joint, with separate codes for the right knee, left knee, and bilateral knees, respectively.

Notably, these codes exclude complications of internal prosthetic devices, implants, and grafts (T82-T85) and fitting and adjustment of prosthetic and other devices (Z44-Z46).

Z47.1 Aftercare following joint replacement surgery
Use additional code to identify the joint (Z96.6-)

This code is used for aftercare following joint replacement surgery, with an additional code required to identify the specific joint (e.g., Z96.6- for the knee). Parent Code Notes for Z47 exclude aftercare for healing fracture-code to fracture with the 7th character D.

  • M17.11 – Unilateral primary osteoarthritis, right knee
  • M17.12 – Unilateral primary osteoarthritis, left knee
  • M17.10 – Osteoarthritis of knee, unspecified

These codes are used to indicate knee osteoarthritis, with separate codes for unilateral primary osteoarthritis of the right knee, left knee, and unspecified knee, respectively.

  1. M16.10 – Unilateral primary osteoarthritis, unspecified hip
  2. M16.11 – Unilateral primary osteoarthritis, right hip
  3. M16.12 – Unilateral primary osteoarthritis, left hip

These codes indicate unilateral primary osteoarthritis of the hip, with separate codes for the unspecified hip, right hip, and left hip, respectively.

HCPCS Codes for Total Knee Replacement

For total knee replacement, there are two HCPCS codes related to shared decision-making:

  1. G9296 – Patients with documented shared decision-making including discussion of conservative (non-surgical) therapy (e.g., NSAIDs, analgesics, weight loss, exercise, injections) prior to the procedure.
  2. G9297 – Shared decision-making including discussion of conservative (non-surgical) therapy (e.g., NSAIDs, analgesics, weight loss, exercise, injections) prior to the procedure, not documented, reason not given.

These codes indicate whether shared decision-making, including discussion of conservative therapy options, was documented prior to the total knee replacement procedure.

Medicare Guidelines for Total Knee Replacement

Medicare guidelines for total knee replacement are subject to change and may vary depending on the specific Medicare Administrative Contractor (MAC) that processes the claims.

In general, Medicare covers total knee replacement procedures when deemed medically necessary and performed by a qualified healthcare provider. The 2021 and 2022 Medicare guidelines for total knee replacement include specific criteria for coverage, such as the patient’s age, medical history, and certain medical conditions.

Indications and Contraindications for Total Knee Replacement

Indications for total knee replacement include severe knee pain and functional limitations that have not responded to conservative treatments, such as medications, physical therapy, and weight loss. Common medical conditions that may indicate the need for total knee replacement include osteoarthritis, rheumatoid arthritis, and post-traumatic arthritis.

Contraindications for total knee replacement include active infection, severe vascular disease, or other medical conditions that may increase the risk of complications or poor outcomes following surgery.

Inpatient vs. Outpatient Total Knee Replacement

Total knee replacement procedures can be performed inpatient or outpatient, depending on the patient’s medical condition, the surgeon’s preference, and the specific surgical technique used.

Criteria for determining inpatient vs. outpatient status for total knee replacement may include the patient’s overall health, the presence of comorbidities, and the anticipated length of the hospital stay.

Modifiers

Here are some scenarios where modifiers may be used in the context of total knee replacement.

Scenario 1: Bilateral Total Knee Replacement

If a patient undergoes bilateral total knee replacement during the same operative session, the CPT code 27447 should be reported with the modifier -50 (Bilateral Procedure) to indicate that the procedure was performed on both knees.

The billing would look like this:

  • CPT Code: 27447-50
  • ICD-10 Code: Z96.653 (Presence of artificial knee joint, bilateral)

Scenario 2: Staged or Planned Total Knee Replacement

If a patient undergoes staged or planned total knee replacement, where the second knee replacement is performed within a specific time frame (e.g., within 90 days), the CPT code 27447 should be reported with the modifier 58 (Staged or Related Procedure or Service by the Same Physician During the Postoperative Period) for the second procedure.

The billing would look like this:

First Procedure:

  • CPT Code: 27447
  • ICD-10 Code: Z96.651 (Presence of right artificial knee joint) or Z96.652 (Presence of left artificial knee joint)

Second Procedure:

  • CPT Code: 27447-58
  • ICD-10 Code: Z96.651 (Presence of right artificial knee joint) or Z96.652 (Presence of left artificial knee joint)

Scenario 3: Total Knee Replacement with Additional Procedures

If a patient undergoes total knee replacement and an additional procedure during the same operative session, such as a removal of a loose body in the knee joint, the additional procedure should be reported with the modifier 51 (Multiple Procedures) to indicate that more than one procedure was performed.

The billing would look like this:

  • CPT Code: 27447
  • ICD-10 Code: M17.11 (Unilateral primary osteoarthritis, right knee) or M17.12 (Unilateral primary osteoarthritis, left knee)

Additional Procedure:

  • CPT Code: 29874-51 (Arthroscopy, knee, surgical; for removal of loose body or foreign body)
  • ICD-10 Code: M25.561 (Loose body in right knee) or M25.562 (Loose body in left knee)

Scenario 4: Total Knee Replacement with Assistant Surgeon

If an assistant surgeon is required during the total knee replacement procedure, the CPT code 27447 should be reported with the modifier 80 (Assistant Surgeon) for the assistant surgeon’s services.

The billing would look like this:

Primary Surgeon:

  • CPT Code: 27447
  • ICD-10 Code: M17.11 (Unilateral primary osteoarthritis, right knee) or M17.12 (Unilateral primary osteoarthritis, left knee)

Assistant Surgeon:

  • CPT Code: 27447-80
  • ICD-10 Code: M17.11 (Unilateral primary osteoarthritis, right knee) or M17.12 (Unilateral primary osteoarthritis, left knee)

Examples

Below are billing examples of total knee replacement. These clinical examples demonstrate scenarios where CPT, ICD-10, and HCPCS codes and modifiers may be billed for total knee replacement procedures.

Example 1: Primary Total Knee Replacement

A 65-year-old patient with severe osteoarthritis in the left knee undergoes a primary total knee replacement. The patient has tried conservative treatments without significant improvement, including NSAIDs, physical therapy, and weight loss.

The billing is as follows:

  • CPT Code: 27447 (Total knee arthroplasty)
  • ICD-10 Code: M17.12 (Unilateral primary osteoarthritis, left knee)
  • HCPCS Code: G9296 (Documented shared decision-making including discussion of conservative therapy)

Example 2: Bilateral Total Knee Replacement

A 70-year-old patient with severe osteoarthritis in both knees undergoes bilateral total knee replacement during the same operative session.

Billing is as follows:

  • CPT Code: 27447-50 (Total knee arthroplasty, bilateral procedure)
  • ICD-10 Code: Z96.653 (Presence of artificial knee joint, bilateral)

Example 3: Total Knee Replacement with Manipulation under Anesthesia

A 60-year-old patient with severe osteoarthritis in the right knee undergoes a total knee replacement. Six weeks postoperatively, the patient has limited range of motion and undergoes manipulation under anesthesia to improve knee function.

Billing is as follows:

  • CPT Code (Total Knee Replacement): 27447 (Total knee arthroplasty)
  • ICD-10 Code (Total Knee Replacement): M17.11 (Unilateral primary osteoarthritis, right knee)
  • CPT Code (Manipulation under Anesthesia): 27570-58 (Manipulation of knee joint under general anesthesia, staged or related procedure)

Example 4: Total Knee Replacement with Removal of Loose Body

A 55-year-old patient with severe osteoarthritis in the left knee and a loose body in the joint undergoes a total knee replacement and removal of the loose body during the same operative session.

Billing is as follows:

  • CPT Code (Total Knee Replacement): 27447 (Total knee arthroplasty)
  • ICD-10 Code (Total Knee Replacement): M17.12 (Unilateral primary osteoarthritis, left knee)
  • CPT Code (Loose Body Removal): 29874-51 (Arthroscopy, knee, surgical; for removal of loose body or foreign body, multiple procedures)
  • ICD-10 Code (Loose Body Removal): M25.562 (Loose body in left knee)

Example 5: Revision Total Knee Replacement

A 68-year-old patient with a history of total knee replacement in the right knee ten years ago presents pain and instability due to the loosening of the prosthesis. The patient undergoes a revision total knee replacement.

Billing is as follows:

  • CPT Code: 27487 (Revision of total knee arthroplasty)
  • ICD-10 Code: Z96.651 (Presence of right artificial knee joint)

Example 6: Total Knee Replacement with Assistant Surgeon

A 75-year-old patient with severe osteoarthritis in the right knee undergoes a total knee replacement with the assistance of an assistant surgeon due to the case’s complexity.

Billing is as follows:

  • CPT Code (Primary Surgeon): 27447 (Total knee arthroplasty)
  • ICD-10 Code (Primary Surgeon): M17.11 (Unilateral primary osteoarthritis, right knee)
  • CPT Code (Assistant Surgeon): 27447-80 (Total knee arthroplasty, assistant surgeon)
  • ICD-10 Code (Assistant Surgeon): M17.11 (Unilateral primary osteoarthritis, right knee)

Example 7: Staged Bilateral Total Knee Replacement

A 72-year-old patient with severe osteoarthritis in both knees undergoes staged bilateral total knee replacement, with the left knee replaced first and the right knee replaced three months later.

Billing is as follows:

First Procedure:

  • CPT Code: 27447 (Total knee arthroplasty)
  • ICD-10 Code: M17.12 (Unilateral primary osteoarthritis, left knee)

Second Procedure:

  • CPT Code: 27447-58 (Total knee arthroplasty, staged or related procedure)
  • ICD-10 Code: M17.11 (Unilateral primary osteoarthritis, right knee)

Example 8: Total Knee Replacement with Synovectomy

A 63-year-old patient with rheumatoid arthritis and severe joint destruction in the left knee undergoes a total knee replacement and synovectomy during the same operative session.

Billing is as follows:

  • CPT Code (Total Knee Replacement): 27447 (Total knee arthroplasty)
  • ICD-10 Code (Total Knee Replacement): M05.552 (Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement)
  • CPT Code (Synovectomy): 29875-51 (Arthroscopy, knee, surgical; synovectomy, limited, multiple procedures)
  • ICD-10 Code (Synovectomy): M65.362 (Synovitis and tenosynovitis, left knee)

Example 9: Total Knee Replacement with Patellar Resurfacing

A 58-year-old patient with severe osteoarthritis in the right knee undergoes a total knee replacement with patellar resurfacing.

Billing is as follows:

  • CPT Code: 27447 (Total knee arthroplasty, including patellar resurfacing)
  • ICD-10 Code: M17.11 (Unilateral primary osteoarthritis, right knee)

Example 10: Total Knee Replacement with Intraoperative Nerve Block

A 64-year-old patient with severe osteoarthritis in the left knee undergoes a total knee replacement with an intraoperative nerve block for postoperative pain management.

Billing is as follows:

  • CPT Code (Total Knee Replacement): 27447 (Total knee arthroplasty)
  • ICD-10 Code (Total Knee Replacement): M17.12 (Unilateral primary osteoarthritis, left knee)
  • CPT Code (Nerve Block): 64447-59 (Injection, anesthetic agent; femoral nerve, distinct procedural service)
  • ICD-10 Code (Nerve Block): G89.18 (Other acute postprocedural pain)

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