Total hip arthroplasty (THA), hemiarthroplasty, or acetabular reconstruction; with or without autograft or allograft
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Total hip arthroplasty billed without documented hip pathology requiring replacement
Occasional27130 (total hip arthroplasty) requires documentation of severe hip pathology (advanced osteoarthritis, avascular necrosis, fracture) necessitating replacement. Very high-value procedure - strict medical necessity criteria. Denied when conservative treatment not documented as failed, or when diagnosis doesn't support replacement.
Common Causes
- • Mild-moderate arthritis documented - may not meet replacement criteria without failed conservative treatment
- • No documentation of conservative treatment trial (PT, injections, NSAIDs)
- • Hip pain alone without imaging showing severe joint destruction
Resolution Strategy
Document medical necessity: 'Patient with severe hip osteoarthritis, Kellgren-Lawrence Grade 4, complete joint space loss on radiographs. Failed conservative treatment: 6 months PT, 3 steroid injections, maximum NSAIDs - no relief. Significant functional limitation (unable to walk >50 feet). Total hip arthroplasty performed with cemented femoral stem and acetabular component.' Must show: severe pathology (imaging), failed conservative treatment, functional limitation, components used. Appeal with documentation supporting medical necessity.
💬 Plain Language Explanation
What this means
This is a total hip replacement surgery - a major surgery where your damaged hip joint is replaced with an artificial joint.
Why you might see this
This is a major surgical procedure. You might see this if you had severe hip arthritis or hip damage that required joint replacement surgery. This is one of the most common orthopedic surgeries.
Common context
Common major orthopedic surgery for severe hip arthritis or damage, usually done when other treatments haven't worked.
What to ask your provider
"'Why was hip replacement necessary? What type of artificial joint was used? What's my recovery timeline?'"
Relative Value Units (RVUs)
Calculator →
Clinical Information
When to Use
For total hip arthroplasty or hemiarthroplasty including acetabular reconstruction with or without autologous or allogenic bone grafting
Common Scenarios
Documentation Requirements
- Type of arthroplasty (total vs. hemi)
- Implant components used
- Autograft/allograft type if used
- Approach (anterior, lateral, posterior)
- Operative time and complications
Coding Guidelines
Common Modifiers
Bundling Rules
- Includes prosthetic components
- Bone grafting included if used
- Fixation method included
Exclusions
- Revision hip uses different codes
- Component removal without replacement
- Infection management may add complexity
Coding Notes
Clinical scenarios
- Type of arthroplasty (total vs. hemi)
- Implant components used
- Autograft/allograft type if used
- Type of arthroplasty (total vs. hemi)
- Implant components used
- Autograft/allograft type if used
- Type of arthroplasty (total vs. hemi)
- Implant components used
- Autograft/allograft type if used
Who are you?
Code Details
Medicare Pricing
PFSRVU Breakdown
OPPS Details
Automate Coding
Let OrbDoc AI automatically suggest codes from your clinical notes.
Patient? Check your bill.
Use our free analyzer to understand charges and spot errors.
Analyze My BillAsk OrbDoc AI
Get instant answers about 27130 - pricing, bundling rules, or billing questions.
Ask a QuestionFrequently Asked Questions
CPT 27130 is the billing code for "Total hip arthroplasty (THA), hemiarthroplasty, or acetabular reconstruction; with or without autograft or allograft". For total hip arthroplasty or hemiarthroplasty including acetabular reconstruction with or without autologous or allogenic bone grafting
Medicare pays approximately $1259.25 for CPT 27130 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 27130 has a total RVU of 50.34, broken down as: Work RVU 22.68, Practice Expense RVU 25.51, and Malpractice RVU 2.15. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 27130 is "Total hip arthroplasty billed without documented hip pathology requiring replacement". 27130 (total hip arthroplasty) requires documentation of severe hip pathology (advanced osteoarthritis, avascular necrosis, fracture) necessitating replacement. Very high-value procedure - strict medical necessity criteria. Denied when conservative treatment not documented as failed, or when diagnosis doesn't support replacement. Common causes include: Mild-moderate arthritis documented - may not meet replacement criteria without failed conservative treatment; No documentation of conservative treatment trial (PT, injections, NSAIDs). Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 27130 include: Type of arthroplasty (total vs. hemi); Implant components used; Autograft/allograft type if used; Approach (anterior, lateral, posterior). Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 27130: Includes prosthetic components. Bone grafting included if used Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 27130 include: 22 (Increased complexity if revision), 51 (Multiple procedures if other performed), 62 (Co-surgeon if applicable). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 27130 is 120-150 minutes typical procedure time. Time-based codes require documentation of the actual time spent providing the service.