If you're an orthopedic practice handling total hip replacements, CPT 27130 is likely a staple in your billing lineup. But navigating Medicare Part B rules can feel like threading a needle—especially with updates rolling out each year. In 2025, the focus remains on solid documentation and medical necessity to avoid denials and keep reimbursements flowing. Whether you're searching for "Medicare CPT 27130 billing guidelines 2025" or "orthopedics total hip arthroplasty reimbursement Medicare," this guide breaks it down simply, so you can bill confidently and get back to patient care.

What Is CPT 27130 and When Does Medicare Cover It?

CPT 27130 describes arthroplasty of the acetabular and proximal femoral components—essentially a total hip replacement, with or without grafts. It's a go-to for severe hip conditions like osteoarthritis or fractures that haven't responded to conservative treatments.

Medicare Part B covers this under the Physician Fee Schedule (PFS) when it's medically necessary. Key criteria include documented evidence of pain, functional limitations, and failed non-surgical options like meds or PT. For 2025, no big shifts in coverage basics, but always check your MAC's Local Coverage Determination (LCD)—like L36573—for specifics on reasonable and necessary thresholds.

2025 Billing Guidelines: Key Updates and Essentials

Billing CPT 27130 under Medicare Part B in 2025 follows familiar PFS rules, with payment rates adjusted slightly. Overall PFS rates dip by 2.93% from 2024, but for high-volume ortho codes like 27130, expect a modest 0.28% bump in reimbursement. National averages hover around $1,300–$1,500 for the professional component, varying by location and modifiers.

Core billing tips:

• Pair with ICD-10 Codes: Use Group 1 codes from articles like A57765, such as M16.11 (unilateral primary osteoarthritis) to support necessity.
• Modifiers Matter: Add -LT/-RT for side, or -50 for bilateral (with documentation). Global period is 90 days, so watch for post-op visits.
• Site of Service: Often inpatient (Part A), but if outpatient or ASC, bill under Part B—confirm via the Procedure Price Lookup tool.
• Documentation Essentials: Notes should detail pre-op imaging, conservative care failure, and procedure specifics to meet audit standards.

Stay on top of PFS final rule tweaks—effective January 1, 2025—for any nuanced changes in work RVUs or practice expense.

Common Denials for CPT 27130 and How to Fix Them

Denials often stem from missing medical necessity or coding mismatches. CO-236 (procedure not paid separately) or CO-97 (bundled) can pop up if grafts aren't justified.

To resolve:

1. Review the EOB: Pinpoint the reason code.
2. Gather Records: Include X-rays, history, and LCD compliance proof.
3. Appeal Promptly: Submit via your MAC portal within 120 days—many overturn with strong evidence.

Proactive scrubs can keep first-pass rates above 90%.

Preventing Billing Pitfalls in Your Ortho Practice

The best fix is prevention: Integrate real-time code checks into your EHR to flag ICD mismatches pre-submission. Train staff on 2025 PFS updates quarterly, and use tools for eligibility verification to avoid surprises.

Ortho groups automating these steps report fewer denials and faster AR turns.

Ready to Optimize CPT 27130 Billing?

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