Medicare Benefits Schedule - Note TN.8.117

The Medical Services Advisory Committee (MSAC) evaluated the available evidence and did not support public funding for matrix-induced autologous chondrocyte implantation (MACI) or autologous chondrocyte implantation (ACI) for the treatment of chondral defects in the knee and other joints, due to the increased cost compared to existing procedures and the lack of evidence showing short term or long-term improvements in clinical outcomes. Medicare benefits are not payable in association with this technology as per GN.13.33.

Related Items: 49500 49503 49506 49509 49512 49515 49516 49517 49518 49519 49521 49524 49525 49527 49530 49533 49534 49536 49542 49544 49548 49551 49554 49564 49565 49569 49570 49572 49574 49576 49578 49580 49582 49584 49586 49590

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Multiple Operation Rule

Knee, arthrotomy of, involving one or more of capsular release, biopsy or lavage, or removal of loose body or foreign body (H)

(Anaes.) (Assist.)

Fee: $414.45 Benefit: 75% = $310.85

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Arthrotomy of knee, including one of the following:

(a) meniscal surgery;

(b) repair of collateral or cruciate ligament;

(c) patellectomy;

(d) single transfer of ligament or tendon;

(e) repair or replacement of chondral or osteochondral surface (excluding prosthetic replacement);

other than a service associated with a service to which another item in this Group applies (H)

(Anaes.) (Assist.)

Fee: $538.90 Benefit: 75% = $404.20

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Arthrotomy of knee, including 2 or more of the following:

(a) meniscal surgery;

(b) repair of collateral or cruciate ligament;

(c) patellectomy;

(d) single transfer of ligament or tendon;

(e) repair or replacement of chondral or osteochondral surface (excluding prosthetic replacement);

other than a service associated with a service to which another item in this Group applies (H)

(Anaes.) (Assist.)

Fee: $808.35 Benefit: 75% = $606.30

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Total synovectomy of knee, by open procedure, other than a service performed in association with a service to which another item in this Schedule applies if the service described in the other item is for the purpose of performing an arthroplasty (H)

(Anaes.) (Assist.)

Fee: $829.10 Benefit: 75% = $621.85

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Primary or revision arthrodesis of knee, including arthrodesis (H)

(Anaes.) (Assist.)

Fee: $1,450.55 Benefit: 75% = $1,087.95

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Removal of cemented or uncemented knee prosthesis, performed as the first stage of a 2-stage procedure; including:

(a) removal of associated cement; and

(b) insertion of spacer (if required)

(H)

(Anaes.) (Assist.)

Fee: $932.65 Benefit: 75% = $699.50

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Bilateral unicompartmental arthroplasty of femur and proximal tibia of knee (H)

(Anaes.) (Assist.)

Fee: $2,323.70 Benefit: 75% = $1,742.80

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Unicompartmental arthroplasty of femur and proximal tibia of knee (H)

(Anaes.) (Assist.)

Fee: $1,327.85 Benefit: 75% = $995.90

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Total arthroplasty of knee, including either or both of the following (if performed):

(a) revision of patello-femoral joint replacement to total knee replacement;

(b) patellar resurfacing;

other than a service associated with a service to which item 48245, 48248, 48251, 48254 or 48257 applies (H)

(Anaes.) (Assist.)

Fee: $1,450.55 Benefit: 75% = $1,087.95

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Bilateral total arthroplasty of knee, including patellar resurfacing, other than a service associated with a service to which item 48245, 48248, 48251, 48254 or 48257 applies (H)

(Anaes.) (Assist.)

Fee: $2,548.50 Benefit: 75% = $1,911.40

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Complex primary arthroplasty of knee, using revision femoral or tibial components, including either or both of the following (if performed):

(a) ligament reconstruction;

(b) patellar resurfacing;

other than a service associated with a service to which item 48245, 48248, 48251, 48254 or 48257 applies (H)

(Anaes.) (Assist.)

Fee: $1,761.80 Benefit: 75% = $1,321.35

(See para TN.8.117, TN.8.285 of explanatory notes to this Category)

Multiple Operation Rule

Complex primary arthroplasty of knee:

(a) using revision femoral and tibial components; or

(b) using revision femoral or tibial components including anatomic specific allograft of femur or tibia;

including either or both of the following (if performed):

(c) ligament reconstruction;

(d) patellar resurfacing;

other than a service associated with a service to which item 48245, 48248, 48251, 48254 or 48257 applies (H)

(Anaes.) (Assist.)

Fee: $2,072.60 Benefit: 75% = $1,554.45

(See para TN.8.117, TN.8.285 of explanatory notes to this Category)

Multiple Operation Rule

Revision of uni-compartmental arthroplasty of the knee, with femoral or tibial components (or both) with uni-compartmental implants, other than a service associated with a service to which:

(a) item 48245, 48248, 48251, 48254 or 48257 applies; or

(b) another item in this Group applies if the service described in the other item is for the purpose of performing surgery on a knee (H)

(Anaes.) (Assist.)

Fee: $1,761.80 Benefit: 75% = $1,321.35

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Minor revision of total or partial arthroplasty of knee, including either or both of the following:

(a) exchange of polyethylene component (including uni);

(b) insertion of patellar component;

other than a service associated with a service to which item 48245, 48248, 48251, 48254 or 48257 applies (H)

(Anaes.) (Assist.)

Fee: $1,450.55 Benefit: 75% = $1,087.95

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Revision of total or partial arthroplasty of knee, with exchange of femoral or tibial component:

(a) excluding revision of unicompartmental with unicompartmental implants; and

(b) including patellar resurfacing (if performed);

other than a service associated with a service to which item 48245, 48248, 48251, 48254 or 48257 applies (H)

(Anaes.) (Assist.)

Fee: $2,176.35 Benefit: 75% = $1,632.30

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Revision of total or partial arthroplasty of knee, with exchange of femoral and tibial components, excluding revision of unicompartmental with unicompartmental implants, including patellar resurfacing (if performed), other than a service associated with a service to which item 48245, 48248, 48251, 48254 or 48257 applies (H)

(Anaes.) (Assist.)

Fee: $2,798.55 Benefit: 75% = $2,098.95

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Arthroplasty of patella and trochlea of patello-femoral joint of knee, performed as a primary procedure (H)

(Anaes.) (Assist.)

Fee: $800.55 Benefit: 75% = $600.45

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Either:

(a) repair of cruciate ligaments of knee; or

(b) repair or reconstruction of collateral ligaments of knee;

by open or arthroscopic means, including either or both of the following (if performed):

(c) graft harvest;

(d) intraarticular knee surgery;

other than a service associated with a service to which another item of this Schedule applies if the service described in the other item is for the purpose of performing a procedure on the knee by arthroscopic means (H)

(Anaes.) (Assist.)

Fee: $1,036.25 Benefit: 75% = $777.20

(See para TN.8.117, TN.8.182 of explanatory notes to this Category)

Multiple Operation Rule

Reconstruction of anterior or posterior cruciate ligament of knee, by open or arthroscopic means, including any of the following (if performed):

(a) graft harvest;

(b) donor site repair;

(c) meniscal repair;

(d) collateral ligament repair;

(e) extra-articular tenodesis;

(f) any other associated intra-articular surgery;

other than a service associated with a service to which another item of this Schedule applies if the service described in the other item is for the purpose of performing a procedure on the knee by arthroscopic means (H)

(Anaes.) (Assist.)

Fee: $1,450.55 Benefit: 75% = $1,087.95

(See para TN.8.117, TN.8.182 of explanatory notes to this Category)

Multiple Operation Rule

Reconstruction of 2 or more cruciate or collateral ligaments of knee, by open or arthroscopic means, including any of the following (if performed):

(a) ligament repair;

(b) graft harvest donor site repair;

(c) meniscal repair;

(d) any other associated intra-articular surgery;

other than a service associated with a service to which another item of this Schedule applies if the service described in the other item is for the purpose of performing a procedure on the knee by arthroscopic means (H)

(Anaes.) (Assist.)

Fee: $1,688.80 Benefit: 75% = $1,266.60

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Knee, revision of patello-femoral stabilisation (H)

(Anaes.) (Assist.)

Fee: $1,036.25 Benefit: 75% = $777.20

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Knee, revision of procedures to which item 49536 or 49542 applies (H)

(Anaes.) (Assist.)

Fee: $1,450.55 Benefit: 75% = $1,087.95

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Revision of total replacement of knee, by anatomic specific allograft of tibia or femur, other than a service to which item 48245, 48248, 48251, 48254 or 48257 applies (H)

(Anaes.) (Assist.)

Fee: $2,072.60 Benefit: 75% = $1,554.45

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Stabilisation of patellofemoral joint of knee, by combined open and arthroscopic means, including either or both of the following (if performed):

(a) medial soft tissue reconstruction and tendon transfer;

(b) tibial tuberosity transfer with bone graft and internal fixation;

other than a service associated a service to which another item of this Schedule applies if the service described in the other item is for the purpose of performing a procedure on the knee by arthroscopic means (H)

(Anaes.) (Assist.)

Fee: $1,011.65 Benefit: 75% = $758.75

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Reconstruction of patellofemoral joint of knee, by combined open and arthroscopic means, including:

(a) both of the following:

(i) medial soft tissue reconstruction;

(ii) tibial tuberosity transfer; and

(b) any of the following (if performed):

(i) bone graft;

(ii) internal fixation;

(iii) trochleoplasty;

other than a service associated a service to which another item of this Schedule applies if the service described in the other item is for the purpose of performing a procedure on the knee by arthroscopic means (H)

(Anaes.) (Assist.)

Fee: $1,451.95 Benefit: 75% = $1,089.00

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Knee, mobilisation for post-traumatic stiffness, by multiple muscle or tendon release (quadricepsplasty) (H)

(Anaes.) (Assist.)

Fee: $829.10 Benefit: 75% = $621.85

(See para TN.8.117 of explanatory notes to this Category)

Multiple Operation Rule

Diagnosis of knee, by arthroscopic means, when the pre-procedure diagnosis is undetermined, including either or both of the following (if performed):

(a) biopsy;

(b) lavage

(H)

(Anaes.) (Assist.)

Fee: $300.45 Benefit: 75% = $225.35

(See para TN.8.117, TN.8.183 of explanatory notes to this Category)

Multiple Operation Rule

Partial meniscectomy of knee, by arthroscopic means, for atraumatic meniscus tear, other than a service to which another item of this Schedule applies if the service described in the other item is for the purpose of treating osteoarthritis (H)

(Anaes.) (Assist.)

Fee: $731.15 Benefit: 75% = $548.40

(See para TN.8.117, TN.8.183 of explanatory notes to this Category)

Multiple Operation Rule

Removal of loose bodies of knee, by arthroscopic means—one or more bodies (H)

(Anaes.) (Assist.)

Fee: $731.15 Benefit: 75% = $548.40

(See para TN.8.117, TN.8.183 of explanatory notes to this Category)

Multiple Operation Rule

Repair of chondral lesion of knee, by arthroscopic means, including either or both of the following (if performed):

(a) microfracture;

(b) microdrilling;

other than  a service performed in combination with a service to which another item of this Schedule applies if the service described in the other item is for the purpose of performing chondral or osteochondral grafts (H)

(Anaes.) (Assist.)

Fee: $731.15 Benefit: 75% = $548.40

(See para TN.8.117, TN.8.183 of explanatory notes to this Category)

Multiple Operation Rule

Release of soft tissue, lateral release or osteoplasty of knee, by arthroscopic means, other than  a service performed in combination with a service to which another item of this Schedule applies if the service described in the other item is for the purpose of stabilising the patellofemoral joint of the knee (H)

(Anaes.) (Assist.)

Fee: $731.15 Benefit: 75% = $548.40

(See para TN.8.117, TN.8.183 of explanatory notes to this Category)

Multiple Operation Rule

Partial meniscectomy of knee, by arthroscopic means, for traumatic meniscus tear (H)

(Anaes.) (Assist.)

Fee: $731.15 Benefit: 75% = $548.40

(See para TN.8.117, TN.8.183 of explanatory notes to this Category)

Multiple Operation Rule

Meniscal repair of knee, by arthroscopic means (H)

(Anaes.) (Assist.)

Fee: $853.70 Benefit: 75% = $640.30

(See para TN.8.117, TN.8.183 of explanatory notes to this Category)

Multiple Operation Rule

Chondral, osteochondral or meniscal graft of knee, by arthroscopic means (H)

(Anaes.) (Assist.)

Fee: $853.70 Benefit: 75% = $640.30

(See para TN.8.117, TN.8.183 of explanatory notes to this Category)

Multiple Operation Rule

Synovectomy of knee, by arthroscopic means, for neoplasia or inflammatory arthropathy, other than a service to which another item of this Schedule applies if the service described in the other item is for the purpose of treating uncomplicated osteoarthritis

(Anaes.) (Assist.)

Fee: $853.70 Benefit: 75% = $640.30 85% = $755.00

(See para TN.8.117, TN.8.183 of explanatory notes to this Category)

Multiple Operation Rule

Excision of ganglion, cyst or bursa of knee, by open or arthroscopic means, performed as an independent procedure, other than a service associated with a service to which another item in this Group applies

(Anaes.) (Assist.)

Fee: $408.95 Benefit: 75% = $306.75 85% = $347.65

(See para TN.8.117, TN.8.183 of explanatory notes to this Category)