CPT® Code 27130

Last Updated: February 2026 | Verified for 2026 AMA CPT & CMS Physician Fee Schedule Guidelines

Quick Reference: CPT 27130

• Official Description: Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft.
• Procedure Type: Primary total hip replacement -- both acetabular (socket) and femoral (ball/stem) components. Not used for revision surgery or hemiarthroplasty.
• Global Period: 90 days (major surgery). Pre-operative and post-operative care are bundled into the surgical payment.
• 2026 wRVU: 20.72 work RVUs (CMS 2026 Physician Fee Schedule). Subject to the 2026 CMS -2.5% efficiency adjustment for non-time-based services.
• 2026 Conversion Factor: $33.40 (non-APM QP) / $33.57 (APM Qualifying Participant).
• DRG Assignment: MS-DRG 469 (with MCC) or MS-DRG 470 (without MCC) for inpatient hospital billing.
• Prior Authorization: Required by most commercial payers (including UnitedHealthcare, Aetna, and others). Traditional Medicare does not require PA; Medicare Advantage plans vary.
• Key Modifiers: RT/LT (laterality), 50 (bilateral), 22 (increased complexity), 59 (distinct service), 54/55 (split surgical care).

CPT 27130 is one of the most frequently performed and highest-value surgical codes in orthopedic practice. It covers primary total hip arthroplasty (THA) -- the complete surgical replacement of the hip joint with prosthetic components -- and is used by orthopedic surgeons, billing specialists, and revenue cycle teams across every care setting from hospital inpatient rooms to ambulatory surgery centers (ASCs). Because this code carries significant reimbursement, a 90-day global period, and intense payer scrutiny, accurate documentation and billing are critical to avoid denials, audits, and underpayment.

1. Procedure Definition & Anatomical Scope

CPT 27130 describes the primary, total replacement of the hip joint. The code applies when the surgeon removes both the damaged femoral head and neck (proximal femur) and the diseased acetabulum (hip socket) and replaces them with prosthetic components. The phrase "with or without autograft or allograft" means the code can be reported whether or not bone graft material is used during the same operative session -- bone grafting does not require a separate CPT code when performed as part of the primary THA.

The surgery typically involves four key steps:

1. Surgical exposure of the hip joint (anterior, posterior, or lateral approach).
2. Removal of the damaged femoral head and preparation of the femoral canal for the stem implant.
3. Reaming and preparation of the acetabulum for the prosthetic cup (with or without cementless press-fit or cemented fixation).
4. Trial reduction and final implant seating, followed by wound closure.

What CPT 27130 does NOT include: It does not cover revision surgery (use 27134-27138), conversion of a previous hip procedure to THA (use 27132), or partial hip replacement/hemiarthroplasty of the femoral head only (use 27125). Using 27130 for these scenarios is one of the most commonly audited coding errors in orthopedics.

2. Medical Necessity & Clinical Indications

Medicare and virtually all commercial payers require that a primary THA (CPT 27130) be medically necessary. The standard criteria, derived from CMS and major payer policies (Aetna, UHC, BCBS), include:

Accepted Diagnoses That Typically Qualify

• Primary or secondary osteoarthritis of the hip -- the most common indication, characterized by radiographic joint space narrowing, osteophyte formation, and subchondral sclerosis.
• Avascular necrosis (AVN) of the femoral head -- particularly Ficat stage III or IV with articular surface collapse.
• Femoral neck fracture -- in older patients where hemiarthroplasty is insufficient or THA yields better functional outcomes.
• Rheumatoid arthritis or inflammatory arthropathy involving the hip joint with structural destruction.
• Posttraumatic arthritis following prior acetabular or femoral fracture.
• Failed prior hip procedures -- use CPT 27132 (conversion) if the prior procedure was a partial or resurfacing procedure.
• Hip dysplasia with severe secondary osteoarthritis.

Conservative Treatment Failure Requirement

Most payers require documented failure of conservative therapy before approving THA. Documentation must show that the patient has tried and failed at least two of the following over an adequate trial period (typically 3-6 months):

• Physical therapy with documented goals and outcomes.
• Anti-inflammatory medications (NSAIDs or corticosteroids).
• Activity modification.
• Intra-articular corticosteroid or viscosupplementation injections.
• Assistive devices (cane, walker).

Payer Alert (2025-2026): UnitedHealthcare updated its medical record documentation requirements for CPT 27130 (effective September 4, 2025) to require submission of complete diagnostic imaging interpretation reports -- including the specialty of the interpreting provider -- as part of prior authorization requests. Claims submitted without this documentation face denial.

Functional Impairment Threshold

Documentation must establish that the hip condition significantly limits activities of daily living (ADLs) -- such as walking, climbing stairs, bathing, or dressing -- and that pain is not adequately controlled with conservative measures. Vague phrases like "hip pain" without functional context are insufficient for medical necessity and will trigger denials.

3. Audit-Proof Documentation Standards

CPT 27130 is a high-dollar code that draws regular scrutiny from Medicare Recovery Audit Contractors (RACs) and commercial payer post-payment auditors. A complete, defensible medical record must contain all of the following elements:

Pre-Operative Documentation Checklist

Operative Report Requirements

The operative note -- not just the surgeon's dictated summary -- must include:

• Surgical approach used (e.g., posterior, anterolateral, direct anterior).
• Specific implant manufacturer, model, and size of all components placed (femoral stem, femoral head, acetabular shell, acetabular liner).
• Method of fixation (cementless press-fit vs. cemented).
• Whether bone graft was used (autograft or allograft) -- included in CPT 27130 without separate billing.
• Intraoperative findings (e.g., degree of articular cartilage destruction, femoral head condition).
• Any complications encountered intraoperatively.

Common Audit Failure: Coders who bill from the surgeon's brief dictated summary -- rather than the full operative report -- miss critical details that auditors use to confirm the procedure matches the billed code. Always review the complete operative note before submitting CPT 27130.

4. ICD-10 Diagnosis Codes & Pairing

CPT 27130 must be paired with a specific, lateralized ICD-10 diagnosis code that establishes medical necessity. General codes like "M25.551 -- Pain in right hip" are not sufficient and will trigger denials. Use the most specific code that reflects the pathology confirmed by imaging and clinical findings.

Critical Coding Rule: Specificity and Laterality

ICD-10 requires side-specific codes for hip pathology. The billed diagnosis code must match the operative side documented in the record and flagged by the modifier (RT or LT). A mismatch -- for example, billing M16.11 (right hip OA) with a left-side procedure -- is a major compliance error that can trigger post-payment audits and recoupment demands.

5. Medicare Coverage, DRG & Reimbursement (2026)

Medicare Part B (Physician Component)

Under the 2026 Medicare Physician Fee Schedule (MPFS), CPT 27130 carries a work RVU of 20.72 -- reflecting the significant physician effort, skill, and time required for total hip replacement. The 2026 conversion factors are:

• Non-APM Qualifying Participant: $33.4009 per RVU (+3.26% from 2025)
• APM Qualifying Participant: $33.5675 per RVU (+3.77% from 2025)

2026 CMS Efficiency Adjustment: CMS finalized a -2.5% efficiency adjustment to the work RVUs of non-time-based services for 2026. This adjustment applies to surgical procedures including CPT 27130, slightly reducing the physician payment compared to what pure RVU multiplication would suggest. Practices should recalculate expected reimbursement using the adjusted wRVU figures from CMS Addendum B of the 2026 MPFS Final Rule.

Medicare Part A (Facility/DRG Component)

When performed in the inpatient hospital setting, CPT 27130 maps to the following MS-DRGs under the Medicare Severity Diagnosis-Related Group system:

Accurate coding of comorbidities and complications (MCC/CC) by the hospital coding team is critical to DRG assignment and can significantly affect facility reimbursement. For FY 2026, CMS set the IPPS operating payment update at 2.6% (3.3% market basket minus 0.7% productivity adjustment), with the national standardized operating amount rising approximately 1.94% year-over-year.

Approximate Medicare Physician Reimbursement

Because geographic practice cost indices (GPCIs) vary by region, total reimbursement differs by locality. National average physician payment for CPT 27130 under Medicare approximates $1,500-$1,800 for the complete surgical package (intra-operative care plus the 90-day global period of post-operative visits). Always verify with your MAC's jurisdiction-specific fee schedule at cms.gov.

ASC Reimbursement

CPT 27130 was added to the Medicare ASC-covered procedures list, making it eligible for reimbursement in the outpatient and ASC setting for appropriately selected patients. ASC facility payments for THA average $8,000-$12,000, compared to $12,000-$20,000+ for inpatient hospital settings. Physician billing remains under the MPFS regardless of site of service.

6. The 90-Day Global Period: Rules & Key Scenarios

CPT 27130 carries a 90-day global surgical period. This is a major procedural designation under CMS global surgery policy. The global period bundles pre-operative visits (the day before surgery) and all routine post-operative care into a single global payment. Understanding what is and is not included in the global period is essential to compliant billing.

What Is Included in the 90-Day Global Period (Cannot Be Separately Billed)

• One pre-operative visit on the day before the surgery.
• Intraoperative services (the surgery itself).
• All routine post-operative E/M visits related to the hip replacement for 90 days post-surgery.
• Wound checks, suture/staple removal, and routine post-operative pain management.
• Review of routine post-operative labs and X-rays related to the THA.

What Can Be Separately Billed During the Global Period (with Modifier)

2026 Global Period Reporting Update: CMS continues expanding its global period data collection requirements. In 2026, practitioners should be aware of HCPCS code G0559, introduced to capture non-surgical postoperative care data. Practices that cannot track and report post-operative services may face compliance scrutiny. Maintain a log of all post-operative visits within the 90-day window and their relationship to the original procedure.

7. Complete Modifier Guide for CPT 27130

8. Prior Authorization Requirements by Payer (2025-2026)

Prior authorization (PA) is now required by most major commercial payers for CPT 27130 and must be obtained before surgery. Performing THA without an active, valid PA from payers that require it will result in claim denial regardless of medical necessity.

What to Include in a PA Submission for CPT 27130

1. Completed PA request form with CPT 27130, ICD-10 diagnosis code, and laterality.
2. Operative plan (approach, implant type, surgeon credentials).
3. Radiology reports with the interpreting radiologist's specialty documented.
4. Physical therapy records (dates of service, goals, progress notes, discharge summary if PT is completed).
5. Documentation of failed conservative treatments with specific dates and outcomes.
6. Surgeon's clinical notes documenting functional limitation severity and patient goals.

9. Code Comparison: CPT 27130 vs. Related Hip Codes

Critical Distinction: Using CPT 27130 when the correct code is 27132 (conversion) or 27134 (revision) is one of the most common -- and most audited -- orthopedic coding errors. Always review the prior surgical history documented in the operative report before code selection. The presence of any pre-existing prosthetic hardware should immediately prompt a review of conversion vs. revision codes.

10. ASC vs. Hospital Inpatient Billing for CPT 27130

CMS added THA (CPT 27130) to the ASC-covered surgical procedures list, enabling Medicare to pay for appropriately selected THA cases performed in ambulatory surgery centers. This reflects broader outpatient migration of joint replacement under enhanced recovery protocols.

Site of Service Comparison

Note on Physician Payment by Site of Service: The surgeon's Medicare physician payment for CPT 27130 is the same base wRVU whether the case is done in a hospital or ASC, though the practice expense component of total RVUs may differ slightly between facility (lower) and non-facility settings. The 2026 CMS final rule also reduced the facility practice expense allocation for physicians, affecting those primarily working in hospital settings.

11. Common Billing Errors & How to Avoid Them

The following errors are the most frequently cited in THA billing audits and cause the highest denial and recoupment rates:

Error 1: Using 27130 for Revision Surgery

Billing CPT 27130 for a procedure that is actually a revision (27134-27138) or conversion (27132) is the single most audited error in hip replacement coding. Always verify whether any prior hip prosthesis is present before assigning 27130.

Error 2: Missing or Incorrect Laterality Modifier

Submitting 27130 without RT or LT modifiers on physician claims, or submitting the wrong side, results in denials and creates compliance risk. The side documented in the operative report must match the modifier and the ICD-10 code.

Error 3: Non-Specific ICD-10 Diagnosis Codes

Codes like "M25.551 -- Pain in right hip" do not establish medical necessity for THA. Use pathology-specific codes such as M16.11 (primary OA right hip) or M87.051 (AVN right femur) that reflect the operative indication documented in the record.

Error 4: Billing Post-Op Visits During the 90-Day Global Period

All routine post-operative hip replacement care within 90 days is bundled into the global payment. Billing E/M visits for routine follow-up (e.g., wound checks, routine range-of-motion assessments) during this period without an appropriate modifier (24, 78, or 79) will be denied and may trigger an overpayment demand.

Error 5: Submitting Without Prior Authorization

Commercial payer PA requirements for CPT 27130 are strictly enforced. Performing elective THA without an active PA from payers that require it will result in outright claim denial, and retroactive PA requests are rarely honored. Implement a pre-authorization workflow that verifies PA at least 5-7 business days before the scheduled surgery date.

Error 6: Separately Billing Included Services

Bone grafting, routine fluoroscopy for component positioning, and standard wound closure are all included in CPT 27130 and cannot be separately billed. NCCI edits will bundle these services and deny them as separate charges.

12. Clinical Billing Scenarios

Scenario 1: Elective Primary THA for Osteoarthritis (Most Common)

Patient: 68-year-old male with 2-year history of right hip pain. X-rays show severe joint space narrowing, osteophytes, and subchondral cysts. Has failed 6 months of physical therapy and two cortisone injections. Functional status significantly impaired -- cannot walk more than one block. Surgeon performs right total hip arthroplasty via posterior approach using a cementless press-fit titanium stem and ceramic femoral head with a UHMWPE acetabular liner.

Correct Billing: CPT 27130-RT | ICD-10: M16.11

Rationale: Primary THA with both components replaced. Right-side laterality modifier required. Specific OA code (M16.11) documents medical necessity. Bone grafting was not performed, but if it had been, it would still be included in 27130.

Scenario 2: THA for Femoral Neck Fracture in an Elderly Patient

Patient: 79-year-old female who falls and sustains a displaced femoral neck fracture (Garden type III) of the right hip. Surgeon reviews patient's pre-existing hip X-rays and notes advanced osteoarthritis of the acetabulum. Decision is made to perform THA rather than hemiarthroplasty due to pre-existing acetabular arthritis and the patient's relatively high functional demand.

Correct Billing: CPT 27130-RT | ICD-10: S72.001A (initial encounter) and M16.11 (pre-existing OA as additional justification)

Rationale: THA chosen over hemiarthroplasty due to acetabular involvement. If hemiarthroplasty alone had been performed (femoral head replacement only, acetabulum not addressed), CPT 27125 would apply. Documentation must clearly state why both components were replaced.

Scenario 3: Bilateral THA in Same Operative Session

Patient: 55-year-old male with bilateral severe primary osteoarthritis affecting both hips. After discussion of risks, patient and surgeon elect to perform simultaneous bilateral THA in one session.

Correct Billing: CPT 27130-50 | ICD-10: M16.0 (bilateral primary OA of hip)

Rationale: Modifier 50 indicates bilateral procedure in a single session. Some commercial payers (e.g., Aetna) require submission as two separate lines (27130-RT and 27130-LT) rather than one line with modifier 50. Always verify payer preference before submitting. Medicare generally accepts 27130-50 on a single line. PA for both sides must be obtained before surgery.

Scenario 4: Patient Returns to ED During Global Period -- Dislocation

Patient: 72-year-old female, 6 weeks post-primary THA, presents to the ED with acute hip dislocation. Orthopedic surgeon called in for closed reduction under sedation.

Correct Billing: CPT 27250-78 (Closed treatment of hip dislocation, without anesthesia, traumatic -- modifier 78 for unplanned return to OR for related procedure during global period)

Rationale: This is a complication of the original THA and falls within the 90-day global period. Modifier 78 must be appended to the treatment code. Only the intraoperative component of the fee is payable -- the global period "restart" does not occur. The original 27130 surgeon or covering partner should bill this if they are the same group/specialty.

Scenario 5: Surgeon Bills with Modifier 22 for Complex Dysplastic Hip

Patient: 42-year-old female with severe developmental dysplasia of the hip (DDH) -- Crowe type III. Severely dysplastic acetabulum requires custom cup placement with structural allograft augmentation. Operating time is significantly extended (5+ hours vs. typical 90-minute primary THA).

Correct Billing: CPT 27130-RT-22 | ICD-10: M16.51

Rationale: Modifier 22 reflects the extraordinary complexity beyond what is typical for a standard primary THA. A detailed operative report must accompany the claim with an explicit explanation of the additional complexity, time, and skill required. Without a complete supporting note, payers will deny modifier 22 and pay the base rate only.

flowchart TD
    A[Hip Procedure Needed] --> B{Is there a pre-existing<br/>hip prosthesis?}
    B -->|No| C{Are BOTH acetabular<br/>and femoral components<br/>being replaced?}
    B -->|Yes| D{What is being done<br/>to the prosthesis?}
    C -->|Yes| E[CPT 27130<br/>Primary Total Hip Arthroplasty]
    C -->|No - Femoral only| F[CPT 27125<br/>Hemiarthroplasty]
    D -->|Converting prior procedure to THA| G[CPT 27132<br/>Conversion to THA]
    D -->|Revising both components| H[CPT 27134<br/>Revision THA - Both]
    D -->|Revising acetabular only| I[CPT 27137<br/>Revision - Acetabular]
    D -->|Revising femoral only| J[CPT 27138<br/>Revision - Femoral]
    D -->|Removing without replacement| K[CPT 27090<br/>Prosthesis Removal]
    E --> L{Laterality?}
    L -->|Right| M[27130-RT]
    L -->|Left| N[27130-LT]
    L -->|Bilateral same session| O[27130-50]