Total Joint Arthroplasty - Hip and Knee coverage codes
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Lists procedure codes judged medically necessary for total hip and total knee arthroplasty for commercial products and related administrative references; affects providers billing Blue Cross Blue Shield - Rhode Island commercial plans.
No material clinical or coverage changes in this revision.
Coverage Criteria
Providers must confirm member benefits and eligibility prior to performing services; benefits are determined by the member's subscriber agreement, member certificate, or employer agreement and those documents supersede this policy. For member‑specific benefit information, contact the provider call center. If services are determined to be non‑covered benefits, providers may not charge the member unless the member has been informed and provided written agreement in advance to assume financial responsibility.
Services that are determined to be not medically necessary may result in denial of payment. Providers should follow applicable participation agreements and administrative guidance; when in doubt, verify coverage and obtain prior authorization per related policies and the web‑based tool to reduce the risk of denied claims.
Procedure Codes and Status
| 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. |
| 27447 | Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty). |
| 27486 | Revision of total knee arthroplasty, with or without allograft; 1 component. |
| 27487 | Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component. |
Provider Actions and Billing Requirements
Prior authorization requirement — follow web-based tool guidance
Certain total hip and total knee arthroplasty procedures may require prior authorization; follow the related 'Prior Authorization via Web-Based Tool for Procedures' policy and confirm prior authorization requirements for the CPT codes listed in this policy (27130, 27132, 27134, 27137, 27138, 27447, 27486, 27487).
- Confirm whether the specific procedure code requires prior authorization using the web-based tool referenced in related policies.
Policy is informational — not a guarantee of payment
This policy is provided for informational purposes and is not a guarantee of payment; providers must apply clinical judgment and follow applicable participation agreements when treating patients.
Verify benefits and eligibility
Verify member-specific benefits and eligibility before providing services; benefits are determined by the member's subscriber agreement, member certificate, and/or employer agreement and supersede this policy.
- Contact the provider call center for member-specific benefit and eligibility information.
Financial responsibility and denial risk — obtain member agreement when applicable
If services are determined to be not medically necessary or are non-covered benefits, the provider may not be paid and may not charge the member unless the member was informed and agreed in writing in advance.
- Review participation agreement provisions related to member billing responsibility.
- Obtain written member agreement in advance if proceeding with non-covered services to avoid denial risk.
Background
Total hip and total knee arthroplasty are surgical procedures that replace native joint surfaces with prosthetic components. This policy section identifies the CPT codes considered medically necessary when clinical criteria are met for commercial products and references related administrative requirements and local coverage guidance. The hip codes include 27130, 27132, 27134, 27137, 27138, and the knee codes include 27447, 27486, 27487; providers should confirm member benefits and prior authorization requirements before scheduling these procedures.
Definitions / Code Lists
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