Medicare Benefits Schedule - Note TN.8.191

For the purpose of acetabular bone grafting:

1. Minor bone grafting is intended to cover Paprosky 1 and 2A defects (i.e. minor acetabular derangement / bone loss). 
2. Major bone grafting is intended to cover Paprosky 2B, 2C, 3A and 3B defects (i.e. major acetabular derangement / bone loss). Outside of the acetabulum, a major bone graft is considered to be structural in nature, such as a substantive impaction femoral graft, a strut allograft, or equivalent.

Related Items: 49318 49319 49372 49374 49376 49378 49380 49382 49384 49386 49388 49390 49392 49394 49396 49398

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Multiple Operation Rule

Total arthroplasty of hip, including minor bone grafting (if performed), other than a service associated with a service to which item 48245, 48248, 48251, 48254 or 48257 applies (H)

(Anaes.) (Assist.)

Fee: $1,577.30 Benefit: 75% = $1,183.00

(See para TN.8.191, TN.8.286 of explanatory notes to this Category)

Multiple Operation Rule

Bilateral total arthroplasty of hip, including minor bone grafting (if performed), other than a service associated with a service to which item 48245, 48248, 48251, 48254 or 48257 applies (H)

(Anaes.) (Assist.)

Fee: $2,771.25 Benefit: 75% = $2,078.45

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, with exchange of head or liner (or both) (H)

(Anaes.) (Assist.)

Fee: $1,104.05 Benefit: 75% = $828.05

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, with exchange of head and acetabular shell or cup, including minor bone grafting (if performed) (H)

(Anaes.) (Assist.)

Fee: $2,050.45 Benefit: 75% = $1,537.85

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, with exchange of head and acetabular shell or cup, including major bone grafting (if performed) (H)

(Anaes.) (Assist.)

Fee: $2,523.70 Benefit: 75% = $1,892.80

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, with revision of femoral component (if there is no requirement for femoral osteotomy), including minor bone grafting (if performed) (H) 

(Anaes.) (Assist.)

Fee: $2,208.05 Benefit: 75% = $1,656.05

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, with revision of femoral and acetabular components (if femoral osteotomy is not required), including minor bone grafting (if performed) (H)

(Anaes.) (Assist.)

Fee: $2,681.35 Benefit: 75% = $2,011.05

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, with revision of femoral and acetabular components (if femoral osteotomy is not required), including major bone grafting (H)

(Anaes.) (Assist.)

Fee: $3,470.05 Benefit: 75% = $2,602.55

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, for pelvic discontinuity, with revision of acetabular component (H)

(Anaes.) (Assist.)

Fee: $4,100.90 Benefit: 75% = $3,075.70

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, with revision of femoral component with femoral osteotomy, including minor bone grafting (if performed) (H)

(Anaes.) (Assist.)

Fee: $2,839.15 Benefit: 75% = $2,129.40

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, including:

(a) revision of both of the following:

(i) femoral component with femoral osteotomy;

(ii) acetabular component; and

(b) minor bone grafting (if performed)

(H)

(Anaes.) (Assist.)

Fee: $3,312.30 Benefit: 75% = $2,484.25

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, including:

(a) revision of both of the following:

(i) femoral component with femoral osteotomy;

(ii) acetabular component; and

(b) major bone grafting

(H)

(Anaes.) (Assist.)

Fee: $3,943.25 Benefit: 75% = $2,957.45

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, including:

(a) either:

(i) revision of femoral component with femoral osteotomy; or

(ii) proximal femoral replacement; and

(b) revision of acetabular component for pelvic discontinuity

(H)

(Anaes.) (Assist.)

Fee: $5,520.50 Benefit: 75% = $4,140.40

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, including:

(a) replacement of proximal femur; and

(b) revision of the acetabular component; and

(c) bone grafting (if performed)

(H)

(Anaes.) (Assist.)

Fee: $4,731.80 Benefit: 75% = $3,548.85

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, including:

(a) removal of prosthesis as stage 1 of a 2-stage revision arthroplasty or as a definitive stage procedure; and

(b) insertion of temporary prosthesis (if performed)

(H)

(Anaes.) (Assist.)

Fee: $3,154.55 Benefit: 75% = $2,365.95

(See para TN.8.191 of explanatory notes to this Category)

Multiple Operation Rule

Revision arthroplasty of hip, including:

(a) revision of femoral component for periprosthetic fracture; and

(b) internal fixation; and

(c) bone grafting (if performed)

(H)

(Anaes.) (Assist.)

Fee: $2,365.95 Benefit: 75% = $1,774.50

(See para TN.8.191 of explanatory notes to this Category)