CPT code 27130, 27447 - Hip knee replacement

procedure code and description

27130- Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft - average fee payment - $1510 -$1520

27447 ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY)

27132 CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT

27134 REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT

27137 REVISION OF TOTAL HIP ARTHROPLASTY; ACETABULAR COMPONENT ONLY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT

27138 REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, WITH OR WITHOUT ALLOGRAFT

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

    Joint replacement surgery has been performed on millions of people over the past several decades and has proved to be an important medical advancement in the field of orthopedic surgery. The hip and knee are the two most commonly replaced joints. The knee is the largest joint in the body and includes the lower end of the femur, the upper end of the tibia and the patella. The knee joint has three compartments, the medial, the lateral and the patellofemoral. The surfaces of these compartments are covered with articular cartilage and are bathed in synovial fluid. The bones of the knee joint work together, allowing the knee to function smoothly. The hip is a large weight bearing joint made up of two components: a ball (femoral head) and socket (acetabulum). These components are covered with articular cartilage and are bathed in synovial fluid produced by a synovial membrane.

    The most common reason for total knee replacement surgery is arthritis of the knee joint. Types of arthritis include osteoarthritis, rheumatoid arthritis and traumatic arthritis (arthritis which occurs as a result of injury). This arthritis causes a severe limitation in the activities of daily living, including difficulty with walking, squatting, and climbing stairs. Pain is typically most severe with activity and patients often have difficulty getting mobilized when seated for a long time. Other findings include chronic knee inflammation or swelling not relieved by rest, knee stiffness, lack of pain relief after taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement with other conservative therapies such as steroid injections and physical therapy. Osteonecrosis and malignancy are additional reasons to proceed with total knee replacement surgery. The goal of total knee replacement surgery is to relieve pain and improve or increase patient function.

    Total hip replacement surgery is most often performed due to severe pain caused by osteoarthritis of the hip joint. Rheumatoid arthritis, traumatic arthritis, malignancy involving the hip joint and osteonecrosis of the femoral head are also causes for hip replacement surgery. The pain from the damaged joint usually limits activities of daily living, such as walking, bathing and cooking. The pain can also cause disruption of sleep due to the inability to lie on the hip while in bed. Pain relief not achieved by taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement with other conservative therapies such as physical therapy, activity modification and (in some patients) assistive device use are reasons for proceeding with a total hip replacement. The goal of total hip replacement surgery is to relieve pain and improve or increase patient function.

    Occasionally, there may be a need to redo a total hip or total knee replacement. This is often referred to as a revision total knee or revision total hip. Circumstances that lead to the need for a revision total hip or knee are continued disabling pain, continued decline in function which can be attributed to failure of the primary joint replacement. Failure can be due to infection involving the joint, substantial bone loss in the structures supporting the prosthesis, fracture, aseptic loosening of the components and wear of the prosthetic components.

Joint replacement surgery has been performed on millions of people over the past several decades and has proved to be an important medical advancement in the field of orthopedic surgery. The hip and knee are the two most commonly replaced joints. The hip is a large weight bearing joint made up of two components: a ball (femoral head) and socket (acetabulum). These components are covered with articular cartilage and are bathed in synovial fluid produced by a synovial membrane.

Arthritis causes a severe limitation in the activities of daily living (ADLs), including difficulty with walking, squatting, and climbing stairs. Pain is typically most severe with activity and patients often have difficulty getting mobilized when seated for a long time.

Total hip replacement surgery is most often performed due to severe pain caused by osteoarthritis (degenerative arthritis) of the hip joint. Rheumatoid arthritis, traumatic arthritis, malignancy involving the hip joint and osteonecrosis of the femoral head are also possible causes for hip replacement surgery. The use of THR in patients with malignancy must be weighed against considerations of life expectancy and possible alternative procedures to relieve pain. The pain from the damaged joint usually limits activities of daily living, such as walking, bathing and cooking. The pain can also cause disruption of sleep due to the inability to lie on the hip while in bed. Pain relief not achieved by taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement with other conservative therapies such as physical therapy, activity modification and (in some patients) assistive device use are reasons for proceeding with a total hip replacement. The goal of total hip replacement surgery is to relieve pain and improve or increase patient function. Occasionally, there may be a need to perform a reoperation on a previous total hip. This is often referred to as a revision total hip. Circumstances that lead to the need for a revision total hip are continued disabling pain, continued decline in function which can be attributed to failure of the primary joint replacement. Failure can be due to infection involving the joint, substantial bone loss in the structures supporting the prosthesis, fracture, aseptic loosening of the components and wear of the prosthetic components.

Total Hip Arthroplasty (THA)

Noridian will consider total hip replacement surgery medically necessary in the following circumstances:

Advanced joint disease demonstrated by:

Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) and/or computed tomography (CT) (in situations when MRI is non-diagnostic or not able to be performed) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, severe joint space narrowing, avascular necrosis); AND


Pain that cannot be adequately controlled despite optimal conservative treatment or functional disability from injury due to trauma or arthritis of the joint); AND


If appropriate, history of unsuccessful conservative therapy (non-surgical medical management) that is clearly addressed in the pre procedure medical record. (If conservative therapy is not appropriate, the medical record must clearly document the rationale for why such approach is not reasonable). Non-surgical medical management is usually but not always implemented prior to scheduling total joint surgery. Non-surgical treatment as clinically appropriate for the patient’s current episode of care typically includes one or more of the following:


anti-inflammatory medications or analgesics, or


flexibility and muscle strengthening exercises, or


supervised physical therapy [Activities of daily living
(ADLs) diminished despite completing a plan of care], or


assistive device use, or


weight reduction as appropriate, or


therapeutic injections into the hip as appropriate.


In some circumstances, for example, if the patient has bone on bone articulation, severe deformity, pain or significant disabling interference with activities of daily living, the surgeon may determine that nonsurgical medical management would be ineffective or counterproductive and that the best treatment option, after explaining the risks, is surgical. If medical management is deemed appropriate, the medical record should indicate the rationale for and the circumstances under which this is the case.

Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or


Avascular necrosis (osteonecrosis of femoral head); or


Fracture of the femoral neck; or


Acetabular fracture; or


Non-union or failure of previous hip fracture surgery; or


Mal-union of acetabular or proximal femur fracture


*See Associated Information - Documentation Requirements for additional information.

Indications for Replacement/Revision of Total Hip Arthroplasty

Loosening of one or both components; or


Fracture or mechanical failure of the implant; or


Recurrent or irreducible dislocation; or


Infection; or


Treatment of a displaced periprosthetic fracture; or


Clinically significant leg length inequality not amenable to conservative management; or


Progressive or substantial bone loss; or

Bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction; or


Clinically significant audible noise; or


Adverse local tissue reaction


    Indications

    Total knee replacement surgery will be considered medically necessary when one or more of the following criteria are met:

    *See Documentation Requirements section for additional information

    Total knee arthroplasty (TKA)

    • Failure of a previous osteotomy; or
    • Distal femur fracture; or
    • Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or
    • Failure of previous unicompartmental knee replacement; or
    • Avascular necrosis of the knee; or
    • Proximal tibia fracture; or
    • Advanced joint disease demonstrated by :

        Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis); and

        Pain or functional disability from injury due to trauma or arthritis of the joint; and

        Unsuccessful history of appropriate conservative therapy (non-surgical medical management) that is clearly addressed in the pre procedure medical record. Non surgical medical management is usually implemented for 3 months or more to assess effectiveness. Conservative treatment as clinically appropriate for the patient’s current episode of care typically include one or more of the following: anti-inflammatory medications, analgesics, flexibility and muscle strengthening exercises, supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care], activity restrictions as is reasonable, assistive device use, weight reduction as appropriate, therapeutic injections into the knee as appropriate.


    Replacement/Revision total knee arthroplasty

    • Disabling pain or functional disability; or
    • Progressive and substantial bone loss; or
    • Fracture or dislocation of the patella; or
    • Infection; or
    • Periprosthetic fracture or aseptic loosening; or
    • Failure and wear of the prosthetic components; or
    • Dislocation of the knee joint; or
    • Instability of the knee joint

    Total hip replacement surgery will be considered medically necessary when one or more of the following criteria are met:

    *See Documentation Requirements for additional information

    Total hip arthroplasty (THA)

    • Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or
    • Avascular necrosis (osteonecrosis of femoral head); or
    • Fracture of the femoral neck; or
    • Acetabular fracture; or
    • Non-union or failure of previous hip fracture surgery; or
    • Mal-union of acetabular or proximal femur fracture; or
    • Advanced joint disease demonstrated by:

        Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis); and

        Pain or functional disability from injury due to trauma or arthritis of the joint); and

        Unsuccessful history of appropriate conservative therapy (non-surgical medical management) that is clearly addressed in the pre procedure medical record. Non surgical medical management is usually implemented for 3 months or more to assess effectiveness. Conservative treatment as clinically appropriate for the patient’s current episode of care typically include one or more of the following: anti-inflammatory medications, analgesics, flexibility and muscle strengthening exercises, supervised physical therapy [Activities of daily living (ADLs) diminished despite completing a plan of care], activity restrictions as is reasonable, assistive device use, weight reduction as appropriate.

    Replacement/Revision total hip arthroplasty


        Instability of one or both components; or

        Fracture or mechanical failure of the implant; or

        Recurrent or irreducible dislocation; or

        Infection; or

        Treatment of a displaced periprosthetic fracture; or

        Clinically significant leg length inequality; or

        Progressive or substantial bone loss; or

        Clinically significant audible noise; or

        Adverse local tissue reaction

    Limitations

    Total knee replacement or total hip replacement will NOT be considered medically necessary when the following contraindications are present:

        Active infection of the hip or knee joint or active systemic bacteremia

        Active skin infection or open wound within the planned surgical site of the hip or knee

        Neuropathic arthritis

        Rapidly progressive neurological disease


    This local coverage determination (LCD) is only addressing medical necessity criteria for performing total hip and knee replacement surgery. With respect to knee replacement surgery, there is a form of knee joint replacement surgery called unicompartmental knee replacement. This is typically done for patients with osteoarthritis of the knee in which the damage is contained to one compartment of the knee. The indications outlined in this LCD are not to be applied for unicompartmental knee replacement surgery. Failed previous unicompartmental joint replacement is an indication for performing a total knee arthroplasty.


Procedure /HCPCS Codes

    27130 Total hip arthroplasty
    27132 Total hip arthroplasty
    27134 Revise hip joint replacement
    27137 Revise hip joint replacement
    27138 Revise hip joint replacement
    Group 2 Paragraph
 
    Total Knee Arthroplasty
 
    27445 Revision of knee joint
    27447 Total knee arthroplasty
    27486 Revise/replace knee joint
    27487 Revise/replace knee joint

Medicare Coverage limitation

Noridian will not consider a total hip replacement medically necessary when the following contraindications are present:

Active infection of the hip joint or active systemic bacteremia


Active urinary tract or dental infection


Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned surgical site of the hip.


Rapidly progressive neurological disease except in the clinical situation of a concomitant displaced femoral neck fracture


The following conditions are relative contraindications to total hip replacement and if such surgery is performed in the presence of these conditions, it is expected that the rationale for proceeding with the surgery under such circumstances is clearly documented in the medical record:

Absence or relative insufficiency of abductor musculature


Any process that is rapidly destroying bone


Neurotrophic arthritis


This local coverage determination (LCD) is only addressing medical necessity criteria for performing total hip replacement surgery.

Billing and Coding Guidelines

A knee replacement occurs in an inpatient setting and the episode is triggered by the  procedure code (27447).The diagnosis codes on the TJR do not disqualify the trigger. The Quarterback is the individual provider or group billing the knee replacement.

Identify the episode trigger

Each TJR episode is triggered by a surgical procedure for total hip replacement or total knee replacement. For example, the following  procedure codes trigger a TJR episode:

• 27130 - Total hip arthroplasty
• 27447 - Total knee arthroplasty

Revision, replacement, and conversion procedures do not qualify as triggers. Further, a TJR with a diagnosis of a fracture, internal injuries, intracranial or crushing injury is disqualified to be a trigger. A trigger must be preceded and followed by a 90-day period clean of another trigger.

Hip Resurfacing Arthroplasty (HRA) (Procedure  codes 27125, 27130, 27299 and HCPCS Code S2118)

* Medicare does not have a National Coverage Determination (NCD) for Total Hip Resurfacing Arthroplasty (THRA).

* Local Coverage Determinations (LCDs) do not exist at this time.

* For coverage guideline, see the UnitedHealthcare Medical Policy for Hip Resurfacing Arthroplasty. (IMPORTANT NOTE: After searching the Medicare Coverage Database, if no state LCD or Local Article is found, then use the above referenced policy.)

* Committee approval date: August 16, 2016

* Accessed July 7, 2016


Hip Replacement Surgery (Arthroplasty)

a. Procedure  codes 27130, 27132, 27134, 27137 and 27138

* Medicare does not have a National Coverage Determination (NCD) for Hip Replacement Surgery (Arthroplasty).

* Local Coverage Determinations (LCDs) exist and compliance with these LCDs is required  where applicable. See the LCD Availability Grid (Attachment A) for state-specific LCDs.

* For states with no LCDs, see the UnitedHealthcare Medical Policy for Hip Replacement Surgery (Arthroplasty) for coverage guidelines. (IMPORTANT NOTE: After searching the Medicare Coverage Database, if no state LCD or Local Article is found, then use the above referenced policy.)

Procedure  Codes 27120, 27122 and 27125

* Medicare does not have a National Coverage Determination (NCD) for Hip Replacement Surgery (Arthroplasty) (Procedure  codes 27120, 27122 and 27125)

* Local Coverage Determinations (LCDs) do not exist at this time.

* For coverage guideline, see the UnitedHealthcare Medical Policy for Hip Replacement Surgery (Arthroplasty) for coverage guidelines. (IMPORTANT NOTE: After searching the Medicare Coverage Database, if no state LCD or Local Article is found, then use the above referenced policy.)



ICD-10 Codes that Support Medical Necessity

    Group 1 Paragraph
    **For inpatient hospital only the following ICD-10 CM PROCEDURE CODES should be used

    Total Hip Arthroplasty

    0SP90JZ Removal of Synthetic Substitute from Right Hip Joint, Open Approach

    0SPB0JZ Removal of Synthetic Substitute from Left Hip Joint, Open Approach

    0SR9019 Replacement of Right Hip Joint with Metal Synthetic Substitute, Cemented, Open Approach

    0SR901A Replacement of Right Hip Joint with Metal Synthetic Substitute, Uncemented, Open Approach

    0SR901Z Replacement of Right Hip Joint with Metal Synthetic Substitute, Open Approach

    0SR9029 Replacement of Right Hip Joint with Metal on Polyethylene Synthetic Substitute, Cemented, Open Approach

    0SR902A Replacement of Right Hip Joint with Metal on Polyethylene Synthetic Substitute, Uncemented, Open Approach

    0SR902Z Replacement of Right Hip Joint with Metal on Polyethylene Synthetic Substitute, Open Approach

    0SR9039 Replacement of Right Hip Joint with Ceramic Synthetic Substitute, Cemented, Open Approach

    0SR903A Replacement of Right Hip Joint with Ceramic Synthetic Substitute, Uncemented, Open Approach

    0SR903Z Replacement of Right Hip Joint with Ceramic Synthetic Substitute, Open Approach

    0SR9049 Replacement of Right Hip Joint with Ceramic on Polyethylene Synthetic Substitute, Cemented, Open Approach

    0SR904A Replacement of Right Hip Joint with Ceramic on Polyethylene Synthetic Substitute, Uncemented, Open Approach

    0SR904Z Replacement of Right Hip Joint with Ceramic on Polyethylene Synthetic Substitute, Open Approach

    0SR907Z Replacement of Right Hip Joint with Autologous Tissue Substitute, Open Approach

    0SR90J9 Replacement of Right Hip Joint with Synthetic Substitute, Cemented, Open Approach

    0SR90JA Replacement of Right Hip Joint with Synthetic Substitute, Uncemented, Open Approach

    0SR90JZ Replacement of Right Hip Joint with Synthetic Substitute, Open Approach

    0SR90KZ Replacement of Right Hip Joint with Nonautologous Tissue Substitute, Open Approach

    0SW90JZ Revision OF Synthetic Substitute in Right Hip Joint, Open Approach

    0SRB019 Replacement of Left Hip Joint with Metal Synthetic Substitute, Cemented, Open Approach

    0SRB01A Replacement of Left Hip Joint with Metal Synthetic Substitute, Uncemented, Open Approach

    0SRB01Z Replacement of Left Hip Joint with Metal Synthetic Substitute, Open Approach

    0SRB029 Replacement of Left Hip Joint with Metal on Polyethylene Synthetic Substitute, Cemented, Open Approach

    0SRB02A Replacement of Left Hip Joint with Metal on Polyethylene Synthetic Substitute, Uncemented, Open Approach

    0SRB02Z Replacement of Left Hip Joint with Metal on Polyethylene Synthetic Substitute, Open Approach

    0SRB039 Replacement of Left Hip Joint with Ceramic Synthetic Substitute, Cemented, Open Approach

    0SRB03A Replacement of Left Hip Joint with Ceramic Synthetic Substitute, Uncemented, Open Approach

    0SRB03Z Replacement of Left Hip Joint with Ceramic Synthetic Substitute, Open Approach

    0SRB049 Replacement of Left Hip Joint with Ceramic on Polyethylene Synthetic Substitute, Cemented, Open Approach

    0SRB04A Replacement of Left Hip Joint with Ceramic on Polyethylene Synthetic Substitute, Cemented, Open Approach

    0SRB04Z Replacement of Left Hip Joint with Ceramic on Polyethylene Synthetic Substitute, Open Approach

    0SRB07Z Replacement of Left Hip Joint with Autologous

    0SRB0J9 Replacement of Left Hip Joint with Synthetic Substitute, Cemented, Open Approach

    0SRB0JA Replacement of Left Hip Joint with Synthetic Substitute, Uncemented, Open Approach

    0SRB0JZ Replacement of Left Hip Joint with Synthetic Substitute, Open Approach

    0SRB0KZ Replacement of Left Hip Joint with Nonautologous Tissue Substitute, Open Approach

    0SWB0JZ Revision of Synthetic Substitute in Left Hip Joint, Open Approach

C40.21 Malignant neoplasm of long bones of right lower limb
C40.22 Malignant neoplasm of long bones of left lower limb
D16.21 Benign neoplasm of long bones of right lower limb
D16.22 Benign neoplasm of long bones of left lower limb
L40.50 Arthropathic psoriasis, unspecified
L40.52 Psoriatic arthritis mutilans
L40.53 Psoriatic spondylitis
L40.54 Psoriatic juvenile arthropathy
L40.59 Other psoriatic arthropathy
M05.061 Felty's syndrome, right knee
M05.062 Felty's syndrome, left knee
M05.09 Felty's syndrome, multiple sites
M05.461 Rheumatoid myopathy with rheumatoid arthritis of right knee
M05.462 Rheumatoid myopathy with rheumatoid arthritis of left knee
M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites
M05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
M05.59 Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
M05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement
M05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement
M05.79 Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement
M05.861 Other rheumatoid arthritis with rheumatoid factor of right knee
M05.862 Other rheumatoid arthritis with rheumatoid factor of left knee
M05.89 Other rheumatoid arthritis with rheumatoid factor of multiple sites
M06.061 Rheumatoid arthritis without rheumatoid factor, right knee
M06.062 Rheumatoid arthritis without rheumatoid factor, left knee
M06.09 Rheumatoid arthritis without rheumatoid factor, multiple sites
M06.861 Other specified rheumatoid arthritis, right knee
M06.862 Other specified rheumatoid arthritis, left knee
M06.89 Other specified rheumatoid arthritis, multiple sites
M07.661 Enteropathic arthropathies, right knee
M07.662 Enteropathic arthropathies, left knee
M08.061 Unspecified juvenile rheumatoid arthritis, right knee
M08.062 Unspecified juvenile rheumatoid arthritis, left knee
M08.09 Unspecified juvenile rheumatoid arthritis, multiple sites
M08.261 Juvenile rheumatoid arthritis with systemic onset, right knee
M08.262 Juvenile rheumatoid arthritis with systemic onset, left knee
M08.29 Juvenile rheumatoid arthritis with systemic onset, multiple sites
M08.3 Juvenile rheumatoid polyarthritis (seronegative)
M08.461 Pauciarticular juvenile rheumatoid arthritis, right knee
M08.462 Pauciarticular juvenile rheumatoid arthritis, left knee
M08.861 Other juvenile arthritis, right knee
M08.862 Other juvenile arthritis, left knee
M08.89 Other juvenile arthritis, multiple sites
M08.961 Juvenile arthritis, unspecified, right knee
M08.962 Juvenile arthritis, unspecified, left knee
M08.99 Juvenile arthritis, unspecified, multiple sites
M12.061 Chronic postrheumatic arthropathy [Jaccoud], right knee
M12.062 Chronic postrheumatic arthropathy [Jaccoud], left knee
M12.09 Chronic postrheumatic arthropathy [Jaccoud], multiple sites
M12.461 Intermittent hydrarthrosis, right knee
M12.462 Intermittent hydrarthrosis, left knee
M12.561 Traumatic arthropathy, right knee
M12.562 Traumatic arthropathy, left knee
M12.861 Other specific arthropathies, not elsewhere classified, right knee
M12.862 Other specific arthropathies, not elsewhere classified, left knee
M13.0 Polyarthritis, unspecified
M13.161 Monoarthritis, not elsewhere classified, right knee
M13.162 Monoarthritis, not elsewhere classified, left knee
M17.0 Bilateral primary osteoarthritis of knee
M17.11 Unilateral primary osteoarthritis, right knee
M17.12 Unilateral primary osteoarthritis, left knee
M17.2 Bilateral post-traumatic osteoarthritis of knee
M17.31 Unilateral post-traumatic osteoarthritis, right knee
M17.32 Unilateral post-traumatic osteoarthritis, left knee
M17.4 Other bilateral secondary osteoarthritis of knee
M17.5 Other unilateral secondary osteoarthritis of knee
M23.51 Chronic instability of knee, right knee
M23.52 Chronic instability of knee, left knee
M24.661 Ankylosis, right knee
M24.662 Ankylosis, left knee
M25.261 Flail joint, right knee
M25.262 Flail joint, left knee
M25.361 Other instability, right knee
M25.362 Other instability, left knee
M25.561 Pain in right knee
M25.562 Pain in left knee
M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter for fracture
M80.051D Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing
M80.051G Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with delayed healing
M80.051K Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with nonunion
M80.051P Age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with malunion
M80.051S Age-related osteoporosis with current pathological fracture, right femur, sequela
M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter for fracture
M80.052D Age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with routine healing
M80.052G Age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with delayed healing
M80.052K Age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with nonunion
M80.052P Age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with malunion
M80.052S Age-related osteoporosis with current pathological fracture, left femur, sequela
M80.061A Age-related osteoporosis with current pathological fracture, right lower leg, initial encounter for fracture
M80.061D Age-related osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with routine healing
M80.061G Age-related osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with delayed healing
M80.061K Age-related osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with nonunion
M80.061P Age-related osteoporosis with current pathological fracture, right lower leg, subsequent encounter for fracture with malunion
M80.061S Age-related osteoporosis with current pathological fracture, right lower leg, sequela
M80.062A Age-related osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture
M80.062D Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with routine healing
M80.062G Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with delayed healing
M80.062K Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with nonunion
M80.062P Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with malunion


Indications

Total Knee Replacement (TKR) surgery must meet one or more of the following:

Advanced joint disease demonstrated by:
Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis); and
Pain and functional disability due to the knee joint; and
History of unsuccessful conservative treatment. Conservative treatment can include: anti-inflammatory medications or analgesics, flexibility and muscle strengthening exercises, supervised physical therapy, assistive device use, weight reduction as appropriate, or therapeutic injections as appropriate;

or

Distinct structural abnormalities such as:
Distal femur fracture;
Proximal tibia fracture;
Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or
Avascular necrosis of the knee;

or

Redo / revision of knee replacement can be necessary with:
Loosening, fracture, and mechanical failure of one or more components;
Failure of previous knee surgery, e.g. unicompartmental knee replacement; previous osteotomy;
Infection;
Periprosthetic fracture or bone loss of distal femur, proximal tibia or patella;
Implant or knee malalignment; or
Tibiofemoral or extensor mechanism instability.
Total Hip Replacement (THR) surgery must meet one or more of the following:
Advanced joint disease demonstrated by:
Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis); and
Pain and functional disability due to the hip; and
History of unsuccessful conservative treatment. Conservative treatment can include: anti-inflammatory medications or analgesics, flexibility and muscle strengthening exercises, supervised physical therapy, assistive device use, weight reduction as appropriate, or therapeutic injections as appropriate;

or

Distinct structural abnormalities such as:
Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur;
Avascular necrosis (osteonecrosis of femoral head); or
Fracture of the femoral neck or acetabulum;

or

Redo / revision of hip replacement can be necessary with:
Loosening, fracture and mechanical failure of one or more components;
Recurrent or irreducible dislocation;
Infection;
Periprosthetic fracture;
Significant leg length inequality; or
Non-union or failure of previous hip fracture surgery.
Limitations

TKR and THR will not be reasonable and necessary when the above indications are not met. 

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