Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 27134 provided on April 6, 2019.
You asked the Plan to pay for CPT code 27134. You say that the medical records support the billing of CPT code 27134. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 27134.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 27134 is Revision of total hip arthroplasty; both components, with or without autograft or allograft. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for CPT code 27134. Our reviewer says that the medical records do not support the billing of CPT code 27134. Our physician reviewer found Current Procedural Terminology (CPT) code 27134 52 LT - Revision of total hip arthroplasty; both components, with or without autograft or allograft does not meet criteria for billing or reimbursement consideration. The medical records submitted do not include documentation of a Revision of total hip arthroplasty; both components, with or without autograft or allograft being performed on April 6, 2019, therefore this service cannot be verified. Per the National Correct Coding Initiative Policy Manual regarding CPT 27134 52 LT - The physician revises a total hip arthroplasty. With the patient in a lateral decubitus position, the physician may access the hip through the previous hip surgery incision. Muscles are reflected. A trochanteric osteotomy may be performed with an oscillating saw. The physician incises the hip joint capsule. Any scar tissue is removed. The physician manually dislocates the hip. Cement is removed from the upper portion of the femoral stem with a motorized or hand instrument. The stem may be removed. If the stem has fractured, the physician may drill a hole in the femoral shaft so that an instrument may remove the broken portion. The physician removes scar tissue and cement from around the acetabular component with chisels and gouges. The acetabular component is removed from its bed. The physician reconstructs the acetabulum with cement or screws and bone graft. The new femoral stem is inserted into the femoral shaft. The physician may augment the area with an autograft or allograft. The physician reduces the hip and closes the capsule. The greater trochanter is wired into place. Suction drains may be placed in the wound. The incision is repaired in layers with sutures, staples, and/or Steri-strips. This code is for a revision of total hip arthroplasty, which includes the acetabular and femoral components. Trochanteric osteotomy and repair, as well as iliopsoas tenotomy, are integral to 27134 and should not be reported separately. Any bone graft harvest is not reported separately. For initial arthroplasty, both components, see 27130. For partial hip replacement, see 27125. For removal of a hip prosthesis, without concurrent revision/replacement, see 27090-27091. This description was not documented in the operative note of the enrollee's medical record, therefore this service cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 27134 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 27134 provided on April 6, 2019.