Joint Procedure Coding and Treatment of Rheumatoid Arthritis
** This article was reviewed and updated on October 20, 2023. **
Joint Procedure Coding and the Treatment of Rheumatoid Arthritis
Treatment for rheumatoid arthritis, a chronic autoimmune disease that causes joint problems, may depend on the specific results the patient and his/her physicians hope to achieve. Is the goal to relieve the symptoms, to slow down or stop the disease progression and prevent joint or organ damage? Whatever the aim, joint surgery may be necessary when more conservative medical treatments fail. In this article, we discuss the eight different types of joint procedures and focus on coding for the various types of hip joint surgeries.
Goals of Treatment for Rheumatoid Arthritis
Many changes have been made in treating rheumatoid arthritis (RA) over the past 20 years, and more changes are expected. It used to be that a physician would suggest an over-the-counter drug, prescribe medication, or give the patient a corticosteroid shot. Then, they would watch and wait until the RA got worse. In other words, the course of action was to treat the symptoms rather than the disease itself.
Today, a rheumatologist prescribes a strong medication right away to stop the disease before significant damage occurs.
According to the Arthritis Foundation, the main goals of treatment for rheumatoid arthritis (RA) are to:
- Stop or reduce the inflammation (bring it to remission) as early as possible
- Relieve symptoms
- Prevent joint and organ damage
- Improve overall well-being and physical function
- Decrease any long-term complications
RA Treatment Options
According to Johns Hopkins Arthritis Center, rheumatoid arthritis treatment includes joint stress reduction, physical and occupational therapy, and surgery. Surgery is not performed as often as it once was due to early and aggressive treatment, but it may be needed to correct any joint damage.
The patient should talk to his/her primary physician, rheumatologist, and orthopedist to determine the best course of treatment based on the individual’s goals, rehabilitation ability, and overall medical status.
Joint Procedures and the 8 Different Types
Joint surgeries are common in the hips and knees but are also performed on other joints, such as the ankles, shoulders, wrists, and elbows. According to the Arthritis Organization, the most common surgical options used to fight against ongoing arthritic pain and disability are as follows:
- Total Joint Replacement (TJR), also known as Total Joint Arthroplasty. The damaged joint is removed, and an implant made from combinations of metal, plastic, and/or ceramic parts is inserted in its place. This implant mimics the movement of the natural joint.
- Minimally Invasive TJR. Similar to the traditional TJR, it replaces a damaged joint; however, shorter incisions are made, and less muscle is cut and reattached.
- Arthrodesis, also known as Fusion. To connect two or more bones in the ankles, wrists, thumbs, fingers, or spine, surgeons form one uninterrupted joint using pins, plates, rods, or other hardware. This allows the bones to grow together and lock the joint in place. An arthrodesis sometimes involves using bone grafts from the patient’s pelvis.
- Synovectomy. The synovium, or lining of the joints, can become inflamed or grow too much in people with inflammatory arthritis, damaging the surrounding cartilage and joints. Surgeons perform open or arthroscopic surgery to remove most or all of the affected synovial tissue.
- Arthroscopy. Small incisions are made, and specialized instruments and a tiny camera are used to fix tears in the soft tissues surrounding the knee, hip, shoulder, and other joints. Damaged cartilage is repaired, and broken, detached cartilage pieces are removed.
- Joint resurfacing. When the knee is involved, joint resurfacing may be referred to as a unicompartmental or partial knee replacement. Surgeons replace just one of the knee’s three compartments with an implant. These include the medial (inside), lateral (outside), or patellofemoral (front) compartment. When the hip is involved, surgeons take out the arthritic cartilage and acetabulum (hip socket) and place a metal cup before reshaping the hip ball and covering it with a metal, rounded prosthesis. The patient’s natural femoral head is preserved.
- Osteotomy. Near a damaged joint, a bone is cut or removed, or a wedge of bone is added. For example, in the knee, this procedure takes the weight off the arthritis-damaged area and places it on the undamaged area. An osteotomy of the hip is often performed to correct hip dysplasia early in life.
- Joint Revision. An implant that has failed, worn, or has become infected is surgically replaced with a new implant.
The most common joint surgeries performed on rheumatic arthritis patients are joint replacement, arthrodesis, and synovectomy, according to Arthritis Health. Total joint replacement is one of the safest and most reliable treatments.
Total Hip Replacement
According to the American College of Rheumatology, approximately 450,000 hip replacements are performed every year in the U.S., and this number continues to grow.
In general, a surgeon carries out a total hip replacement (arthroplasty) in this way:
- Anesthesia is administered.
- The surgeon makes an incision in the side or back of the hip and exposes the bones at the hip joint.
- The joint is dislocated, and the head of the femur is removed from the socket (acetabulum) in the pelvis.
- A bone saw is used to cut off the arthritic femoral head.
- The acetabulum is prepared for its acetabular cup prosthesis using a hemispheric reamer to grind down and shape the socket.
- The acetabular cup, often made of porous titanium metal, is placed into the reshaped socket. This type of cup allows the bone to grow into it as time goes on. Another option may be to attach the acetabular cup to the bone with special bone cement.
- A rounded acetabular ceramic or plastic liner is placed inside the acetabular cup to help ensure smooth movement within the new joint.
- The surgeon prepares the femur bone and inserts the long, narrow prosthetic femoral stem into it. The top of the stem holds a prosthetic ball that replaces the femoral head.
The following 2-minute video also explains how a total hip replacement (arthroplasty) is performed.
CPT Coding for Joint Procedures
CPT codes related to joint procedures are located in the Surgery/Musculoskeletal System section. This section is further broken down by general surgical procedures, surgical procedures based on the anatomic site (pelvis and hip joint, femur and knee joint, shoulder, etc.), application of casts and strapping, and endoscopy/arthroscopy procedures.
The individual categories for surgical procedures based on the anatomic site are further broken down by the treatment approach.
Hip Joint Procedure Codes
Although joint procedures are performed on various joints in the body, for understanding, we will discuss CPT codes related to the hip joint. The coder can then use this knowledge to code for joint procedures on other body parts.
Surgical procedures on the pelvis and hip joint are reported with codes from the following code ranges:
- 26990‑27036, Incision Procedures on the Pelvis and Hip Joint
- 27040‑27080, Excision Procedures on the Pelvis and Hip Joint
- 27086-27096, Introduction or Removal Procedures on the Pelvis and Hip Joint
- 27097‑27187, Repair, Revision, and/or Reconstruction Procedures on the Pelvis and Hip Joint
- 27197‑27269, Fracture and/or Dislocation Procedures on the Pelvis and Hip Joint
- 27275‑27275, Manipulation Procedures on the Pelvis and Hip Joint
- 27279‑27286, Arthrodesis Procedures on the Pelvis and Hip Joint
- 27290‑27295, Amputation Procedures on the Pelvis and Hip Joint
- 27299, Other Procedures on the Pelvis or Hip Joint
To find the CPT codes for joint procedures in the CPT coding manual, look in the Index under the method of treatment, such as Arthrodesis, and the joint, such as Hip Joint. Or you can look under the anatomic site, such as Hip, and the treatment approach, such as Arthrodesis. The correct code can then be verified in the Tabular.
Arthroplasty
Hip arthroplasties are reported with codes from code range 27097-27187, Repair, Revision, and/or Reconstruction Procedures on the Pelvis and Hip Joint. The specific codes include the following:
- 27125, Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)
- 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
The documentation should indicate whether the arthroplasty is an initial procedure or a revision. It should also indicate if it is a total (27130) or partial (27125) replacement and, if partial, the component that is being replaced.
Total hip arthroplasty may or may not be performed with cement and the use of a bulk autograft or allograft for acetabular reconstruction. An autograft is when the graft comes from the patient’s femoral head. With an allograft, the graft comes from a donor.
Partial replacement, called a hemiarthroplasty, is usually performed on hip fractures rather than to treat rheumatoid arthritis. Hence, if the patient is diagnosed with rheumatoid arthritis, a total hip arthroplasty would usually be performed, and code 27130 would be assigned.
Minimally invasive hip TJR should be assigned 27130, just as if it were a TJR of the hip.
Revision of total hip arthroplasty is reported with codes 27134, 27137, and 27138. The documentation should specify the component or components being revised. If an autograft or allograft is part of the procedure, it, too, should be documented.
Conversion from a previously fused hip (arthrodesis) to a total hip arthroplasty today should be documented, and the coder should assign CPT 27132.
Arthrodesis
Hip arthrodeses are reported with codes from code range 27279-27286, Arthrodesis Procedures on the Pelvis and Hip Joint, and include:
- 27284, Arthrodesis, hip joint (including obtaining graft)
- 27286, Arthrodesis, hip joint (including obtaining graft); with subtrochanteric osteotomy
This fusion procedure has been mostly replaced with the hip arthroplasty procedure. However, arthrodesis may be used to treat young people or those who have had an unsuccessful hip replacement. If the documentation specifies the hip arthrodesis included a subtrochanteric osteotomy, assign 27286.
Synovectomy
Hip synovectomies are reported with codes from two different code ranges according to whether it is an open or closed procedure. When an arthroscope is used, it is referred to as a closed procedure.
An open synovectomy of the hip is reported with a code from code range 27040-27080, Excision Procedures on the Pelvis and Hip Joint, specifically:
27054, Arthrotomy with synovectomy, hip joint
This open procedure is considered major surgery and often requires general anesthesia. A medical term ending in -otomy refers to an open approach.
A closed (arthroscopic) synovectomy of the hip is reported with a code from code range 29800-29999, Endoscopy/Arthroscopy Procedures on the Musculoskeletal System, specifically:
29863, Arthroscopy, hip, surgical; with synovectomy
There is no surgical opening made in the body. Instead, small incisions are made through a scope. A medical term ending in -oscopy refers to a closed procedure.
Resurfacing
Hip joint resurfacing is an alternative to total hip replacement (TJR) in patients with advanced hip arthritis. There are many orthopedic procedures with no specific CPT code, and hip joining resurfacing is one of them. There is an unlisted code available, however, that some payers recognize. It is:
27299, Unlisted procedure, pelvis or hip joint
Another option is to use a HCPCS code that some payers may accept:
S2118, Metal-on-metal total hip resurfacing, including acetabular and femoral components
I would check with the individual insurance company to determine their requirements.
Osteotomy
Hip joint osteotomies are, as mentioned above, mainly used to treat hip dysplasia rather than rheumatoid arthritis. The periacetabular osteotomy is the most common type of osteotomy performed for hip dysplasia. This procedure involves the surgeon performing multiple cuts (osteotomies) in the three bones of the pelvis.
Like the unlisted code used for hip joint resurfacing, an unlisted code may be accepted by some payers for a periacetabular osteotomy. It is:
27299, Unlisted procedure, pelvis or hip joint, for periacetabular osteotomy
Still, some other payers recognize the following HCPCS code:
S2115, Osteotomy, periacetabular, with internal fixation
Modifiers and Prosthetic Devices
When coding for orthopedic procedures, be sure to use the appropriate modifiers to show laterality when applicable, such as RT (right), LT (left), 50 (bilateral), F1-F9 (fingers), and TA-T9 (toes).
Co-surgeons generally work together to perform bilateral hip or knee joint replacement during the same encounter. One surgeon works on one hip or knee while the other surgeon works on the other hip or knee. When this is the case, modifier 50 (bilateral) and modifier 62 (co-surgeon) should be appended to the appropriate CPT code.
Furthermore, when a physician implants a prosthetic device during a joint replacement, assign HCPCS Level II code C1776, Joint device (implantable).
Coding for Joint Procedures on Other Anatomic Sites
Codes for joint procedures performed on other anatomic sites, such as the shoulder or knee, can also be located in the Surgery/Musculoskeletal System section and the respective subsection for that anatomic site.
Looking up these procedures in the CPT coding manual Index is the same as for the hip joint procedures. Locate the treatment approach first, such as Arthroplasty, and then the body location, such as Ankle, Elbow, Knee, Wrist, etc. This process will take you to a code(s) you can then verify in the Tabular.
Or start with the name of the joint, such as Shoulder Joint, and then the treatment, such as Arthroplasty. You can then verify the codes in the Tabular.
Related Coding Challenge
Now that you have been versed on the eight different types of joint procedures performed on patients with rheumatoid arthritis, with special emphasis on coding for the different hip joint procedures in CPT, you may want to check your knowledge on a related coding challenge on knee joint replacements. Once you have solved the challenge, you will learn the correct answer and get a detailed rationale. In addition, you will learn the anatomy of the knee, components of a prosthesis, and the surgical steps taken for a knee replacement. Last but not least is a short video showing a knee replacement.
