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
27445 Arthroplasty, knee, hinge prosthesis (e.g., Walldius type)
27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment
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
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.
CONDITIONS OF COVERAGE
Applicable Lines of Business/ Products This policy applies to Oxford Commercial plan membership.
Benefit Type General benefits package
Referral Required
(Does not apply to non-gatekeeper products)
No
Authorization Required
(Precertification always required for inpatient admission)
Yes
Precertification with Medical Director Review Required No Applicable Site(s) of Service
(If site of service is not listed, Medical Director review is required)
Inpatient, Outpatient
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.
Hip and Knee Replacement (CPT Codes 27130, 27446 and 27447)
In the CY 2014 final rule with comment period we established interim final values for three CPT codes for hip and knee replacements that had previously been identified as potentially misvalued codes under the CMS high expenditure procedural code screen. For CY 2014, we established the RUC-recommended work value of 17.48 as interim final work RVUs for CPT code 27446. As we explained in the CY 2014 final rule with comment period, we established interim final work RVUs for CPT codes 27130 and 27447 that varied from those recommended
by the RUC based upon information that we received from the relevant specialty societies. We noted that the information presented by the specialty societies and the RUC raised concerns regarding the appropriate valuation of these services, especially related to the use of the best data source for determining the intraservice time involved in furnishing PFS services. Specifically, there was significant variation between the time values estimated through a survey versus those collected through specialty databases. We characterized our concerns saying, “The divergent recommendations from the specialty societies and the RUC regarding the accuracy of the estimates of time for these services, including both the source of time estimates for the procedure itself as well as the inpatient and outpatient visits included in the global periods for these codes, lead us to take a cautious approach in valuing these services.”
With regard to the specific valuations, we agreed with the RUC’s recommendation to value CPT codes 27130 and 27447 equally. We explained that we modified the RUCrecommended work RVUs for these two codes to reflect the visits in the global period as recommended by the specialty societies, resulting in a 1.12 work RVU increase from the RUCrecommended value for each code. Accordingly, we assigned CPT codes 27130 and 27447 an interim final work RVU of 20.72. We sought public comment regarding, not only the appropriate work RVUs for these services, but also the most appropriate reconciliation for the conflicting information regarding time values for these services as presented to us by the physician community. We also sought public comment on the use of specialty databases as compared to surveys for determining time values, potential sources of objective data regarding procedure times, and levels of visits furnished during the global periods for the services described by these codes.
recommendations for these codes and that it followed its process consistently in developing its recommendations on these codes. All those who commented specifically on the interim final work RVUs for these codes objected to the interim final work RVUs – some citing potential access problems. Commenters suggested that we use more reliable time data. Commenters suggested that valuation should be based on actual time data, which demonstrates that the time for this code has not changed since the last valuation; and thus the work RVUs should not decrease from the CY 2013 values. Among the commenters’ suggestions were using data from the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement (FORCE-TJR), which includes data on more than 15,000 total lower extremity joint arthroplasty procedures, including time in/time out data for at least half of the procedures, and working with the specialty societies to explore the best data collection methods. A commenter suggested restoring the CY 2013 work RVUs until additional time data are available. Another commenter suggested valuing these services utilizing a reverse building block methodology resulting in work RVU of 21.18 for CPT codes 27130 and 22.11 for CPT code 27447. A commenter statedthat the hip and knee replacement codes should be valued differently since they are clinically different procedures. Two commenters expressed concern regarding the use of a final rule to establish interim values for established hip and knee procedures due to the lack of opportunity it provides stakeholders to analyze and comment on reductions prior to implementation.
HIP replacement surgery APPLICABLE CODES – Oxford insurance guideline
The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply.
CPT Code Description
27120 Acetabuloplasty; (e.g., Whitman, Colonna, Haygroves, or cup type)
27122 Acetabuloplasty; resection, femoral head (e.g., Girdlestone procedure)
27125 Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)
27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft
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
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.
