Summary & Overview
CPT 27438: Patellar Prosthesis Replacement
CPT code 27438 describes surgical repair and replacement of a damaged or painful patella with a patellar prosthesis. It captures a targeted orthopedic implant procedure that can be a key component of knee reconstructive care. Nationally, this code matters because patellar-specific interventions affect surgical case mix, implant utilization, and procedure-level reimbursement in orthopedic practices and hospitals.
Key payers included in the analysis are Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find clinical context for when a patellar prosthesis is used, typical sites of service, and common billing practices tied to this code. The publication also outlines benchmarking considerations and policy factors that influence coverage and payment, including how implant procedures are billed and documented.
The report provides benchmarks and practical coding context for clinicians, billers, and policy analysts: typical utilization patterns, payer coverage considerations, and documentation elements that support use of CPT code 27438. Data not available in the input is noted where applicable. The focus remains national in scope and aims to clarify the code's clinical purpose and billing implications for stakeholders across care settings.
Billing Code Overview
CPT code 27438 describes a surgical procedure in which a provider repairs and replaces a damaged or painful patella (kneecap) with an artificial patellar prosthesis. This procedure addresses structural damage, degeneration, or chronic pain localized to the patella and is performed to restore articulation and reduce pain.
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Service type: Orthopedic surgical implant procedure
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Typical site of service: Hospital operating room or ambulatory surgical center
Clinical & Coding Specifications
Clinical Context
A typical patient is a 60-year-old female with chronic anterior knee pain and progressive patellofemoral arthritis refractory to conservative care (physical therapy, NSAIDs, corticosteroid injections). The patient reports activity-limiting pain with stair climbing and kneeling and has anterior knee crepitus and tenderness over the patella on exam. Imaging (weight-bearing radiographs and MRI) demonstrates isolated advanced patellofemoral osteoarthritis with patellar cartilage loss and subchondral changes. After failing nonoperative management, the orthopedic surgeon schedules a patellar resurfacing with patellar button prosthesis to replace the damaged patella surface to reduce pain and improve function. The clinical workflow includes preoperative evaluation (medical clearance, anesthesia assessment), perioperative administration of antibiotics, regional or general anesthesia, surgical exposure of the patella, debridement of damaged cartilage, measurement and preparation of the patellar bone, cementation and placement of a patellar button prosthesis, hemostasis, layered closure, and postoperative recovery with physical therapy and discharge planning. Typical site of service is an inpatient or outpatient hospital operating room or ambulatory surgery center depending on patient comorbidities and facility capabilities. Documentation should include indications, informed consent, intraoperative findings, device description and size, laterality (LT or RT), and any applicable modifiers for reporting professional and technical components or unusual circumstances.
Coding Specifications
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