Orthopedic billing is challenging and requires attention to detail, especially when it involves complex surgical interventions. One such procedure is a total knee arthroplasty, which is billed using CPT code 27447. However, billing errors are common while filing claims for joint arthroplasty.
That’s why our billing experts at MediBillMD have compiled this comprehensive guide of CPT code 27447. In this blog, we will provide all the guidelines necessary for accurate billing, including modifiers and documentation requirements. So, let’s start.
CPT Code 27447 – Description
The official definition defines CPT code 27447 as “Arthroplasty, knee, condyle, and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty).”
Simply put, it represents a complete knee replacement procedure. During the surgery, a surgeon replaces both medial and lateral compartments of the knee joint with artificial implants. Surgeons may sometimes choose to resurface the patella (kneecap) during this procedure. However, this is optional, varies from case to case, and is based on medical necessity.
If done right, total knee arthroplasty is among the most long-lasting orthopedic treatments. However, successful completion of the surgery involves many complex steps, such as:
- Removing damaged bone and cartilage.
- Shaping remaining bone surfaces to accommodate prosthetic components.
- Positioning trial implants to ensure proper fit and alignment.
- Cementing final implants in place.
Total knee arthroplasty usually takes between 1-3 hours but may take longer depending on the patient’s condition. An important thing to note here is that CPT code 27447 does not include the cost of anesthesia. So, the biller must use the appropriate anesthesia CPT code for knee surgeries (01402) in their claim.
Scenarios Where CPT Code 27447 is Applicable
The following clinical scenarios may make a total knee arthroplasty (covered by CPT code 27447) medically necessary.
Primary Osteoarthritis
The most common use of total knee arthroplasty is for patients with end-stage primary osteoarthritis that affects both compartments. Consider a 65-year-old patient who visits an orthopedic practice complaining of persistent knee pain and difficulty in moving. The orthopedist performs radiography, which shows narrowing spaces. Also, the patient is not responding well to conservative treatments like physical therapy, weight management, and medication. So, the orthopedist performs a complete knee arthroplasty and bills the procedure with CPT code 27447.
Post-Traumatic Arthritis
Patients who have experienced knee injuries or surgeries in the past can develop post-traumatic arthritis, which often requires knee replacement. Let’s take an example of a 52-year-old construction worker. The patient had a tibial fracture five years ago but was cured at the time. Now he is experiencing slow but progressive joint degeneration and pain. The orthopedist first opted for conservative treatment. However, they were unable to provide relief. As a last resort, he performs a total knee arthroplasty, which is billed with CPT code 27447.
Applicable Modifiers for CPT Code 27447
The following modifiers can be appended to CPT code 27447 (when needed) to provide supplemental information to the insurance payer and collect accurate reimbursement.
| Modifier Code | Modifier Name | Description |
|---|---|---|
| 22 | Increased Procedural Services | Applied if the surgery is unusually complex, requiring extra effort. |
| 50 | Bilateral Procedure | Used when total knee arthroplasty is performed on both knees in one session. |
| 59 | Distinct Procedural Service | Indicates a separate procedure during the same session, like an unrelated arthroscopy. |
| 80 | Assistant Surgeon | Used when a medical doctor provides the assistant surgeon’s services. |
| 81 | Minimum Assistant Surgeon | Used when a medical doctor acts as an assistant surgeon for a limited part of the surgery. |
| 82 | Assistant Surgeon (No Resident) | Used when a medical doctor provides assistant surgeon services and no qualified resident is available. |
| AS | Non-Physician Assistant Surgeon | Used when the assistant surgeon services are provided by a Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), or Registered Nurse First Assistant (RFNA). |
| LT | Left Side | Specifies that the left knee was operated on. |
| RT | Right Side | Specifies that the right knee was operated on. |
CPT Code 27447 – Billing & Reimbursement Guidelines
The following billing tips and reimbursement guidelines will help you submit clean and compliant claims for code 27447.
Justify Medical Necessity
Like all other CPT codes, justifying the medical necessity of total knee arthroplasty is vital. Without proper justification, the insurance claims will be denied. Two things that help insurance payers understand the need for a procedure are:
- The correct usage of ICD-10 codes.
- Proper documentation supporting that diagnosis and treatment.
There are hundreds of ICD-10 codes relevant to CPT code 27447, some of them are:
- C40.21: Malignant neoplasm of long bones of the right lower limb
- C40.22: Malignant neoplasm of long bones of left lower limb
- D16.21: Benign neoplasm of the long bones of the right lower limb
- M05.861: Other rheumatoid arthritis with rheumatoid factor of the right knee
- M05.862: Other rheumatoid arthritis with rheumatoid factor of the left knee
- M05.89: Other rheumatoid arthritis with rheumatoid factor of multiple sites
Documentation is the second pillar of successful billing. For a total knee arthroplasty, make sure to include the following records:
- Patient’s history, physical examination findings, diagnostic imaging results, and conservative treatment attempts.
- Operative report including approach, bone preparation, implant specifications, and any complications.
- Post-operative status, discharge planning, and follow-up care instructions.
Confirm Reimbursement Scenario
In ambulatory surgical centers, patients pay an average of $2,102 out-of-pocket, with Medicare covering $8,410 of the total $10,512. The cost breakdown includes a standardized physician fee of $1,257 and a facility fee of $9,255. This setting represents a more cost-effective option for patients seeking knee replacement surgery.
Hospital outpatient departments present a different financial picture for the same procedure. While patients actually pay slightly less out-of-pocket at $1,927, the total procedure cost is substantially higher at $14,123. Medicare pays $12,196 in this setting, absorbing more of the increased costs. The physician fee remains consistent at $1,257, but the facility fee jumps dramatically to $12,866 – nearly $3,600 more than ambulatory centers.
Wrapping Up
CPT code 27447 represents a high complexity and a high-paying orthopedic procedure. So, it is essential to bill it correctly on the first attempt. Otherwise, healthcare providers may face denials and significant financial losses. By following the guidelines mentioned in this blog, you can effectively use 27447 for billing.
If you are facing frequent denials and revenue blocks, consider acquiring orthopedic billing services from professionals like MediBillMD. Their team of certified coders and billing experts can help you file error-free claims on the first attempt.
