Joint Replacement Billing and Coding: A Comprehensive Guide

Joint replacement billing is more complicated than other specialties and necessitates a deeper understanding of providers’ services.

Approximately 35% of joint replacement surgery claims are erroneous, with 25% of medical claims being denied.

High denial rates can jeopardize your practice’s revenue and patient care while bankrupting it. Not only this, but proper documentation before, during, and after a patient visit is essential for joint replacement billing. The billing team must meticulously document and charge for all services rendered. Incomplete patient demographics entry or failure to verify the patient’s eligibility may result in a denied claim. In addition to authorization errors, failure to understand insurer preferences and timelines can stymie revenue collection.

Although having an in-house billing team and properly training your team can help you avoid costly fees and penalties, the joint replacement billing process is too complex for an in-house team. That’s why there is a need to be aware of the joint replacement billing and coding guidelines.

Joint Replacement (Hip and Knee) Billing Guidelines:

The joint replacement billing guidelines begin with the documentation requirements, which are as follows:

  1. All the documents must be kept in the medical record of the patient to be made available to the contractor upon request.
  2. Every record page must be legible and contain pertinent patient identification information (e.g., full name, dates of service[s]). The legible signature of the physician or non-physician practitioner responsible for and giving care to the patient must be included in the documentation.
  3. The submitted medical record must support the selected ICD-10-CM code(s). The service must be described in the CPT/HCPCS code performed.
  4. When a procedure for advanced joint disease is needed, the following should be documented in the medical record:
  • X-ray or MRI evidence of knee or hip arthritis. The X-ray or MRI should show one or more of the following:
  1. subchondral cysts,
  2. periarticular osteophytes,
  3. subchondral sclerosis,
  4.  joint subluxation,
  5. avascular necrosis
  6. joint space narrowing are all possibilities.
  • Hip or knee pain or functional disability. For instance, documented pain that interferes with ADLs (functional disability), pain that worsens with activity commencement, or pain that worsens with weight bearing.
  • Unsuccessful conservative therapy (non-surgical medical management). The documentation should show a history of a reasonable attempt at conservative therapy as appropriate for the patient in their current episode of care (typically three months or more). Documented NSAID trial or contraindication to such therapy, for example, and/or documented supervised physical therapy.
  • Documentation should show that ADLs have been reduced owing to pain and/or disability despite non-surgical medical management.
  • The risk/benefit of non-cardiac surgery, such as TKA or THA, should be addressed correctly in the medical record for patients with substantial conditions or co-morbidities.

Joint Replacement (Hip and Knee) Coding Guidelines:

Bilateral pricing applies to bilateral knee or hip replacement surgery performed during the same visit. Usually, two surgeons work together as co-surgeons, each focusing on a different knee or hip. Modifiers 50 (bilateral procedure) and 62 (co-surgeon) should be added to the relevant CPT procedure code.

The RT and LT modifiers should be used as required.

Joint Replacement CPT Codes:

Procedure CPT Codes
Total Hip Replacement 27130, 27134, 27137, 27138
Total Knee Replacement 27446, 27447, 27487
Total Shoulder Replacement 23470, 23472, 23616

Outsourcing Joint Replacement Billing & Coding

Not all joint replacement medical billing companies are the same, and some may not provide the required services. Planning correctly and selecting an outsourcing partner who suits your demands and ambitions is vital. After all, the billing company you choose is an extension of your practice. Therefore, look over the following factors before working with a joint replacement billing company:

Expertise in joint replacement billing and coding services: Joint replacement has unique billing requirements and issues. To ensure proper billing and coding and faster claims processing, your billing partner must be knowledgeable in your field.

Reliable support: Your companion should never abandon you. Choose a professional medical billing company that will be there for you every step of the process and will offer assistance whenever it is required.

Excellent customer service: With trustworthy support and assistance, you may be confident that you can handle and overcome problems while staying on schedule to meet your financial objectives.

24/7 Medical Billing Services provides all these services and more to ensure that every physician, surgeon, or provider has the assistance they require to manage a thriving joint replacement center.

See also: Orthopedic Billing – All You Wanted To Know!


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