GOHEALTHCARE MSK SPECIALTY PROCEDURE LIBRARY™

Knee Arthroplasty

Operational, Documentation, Medical Necessity, and Prior Authorization
Guide for MSK Specialty Practices, ASCs, Hospital Outpatient
Departments, and Hospitals

Document Profile

Attribute	Detail
Procedure	Knee Arthroplasty (total knee arthroplasty, unicompartmental knee arthroplasty, and revision knee arthroplasty)
Library	GoHealthcare MSK Specialty Procedure Library™
Standard	GoHealthcare Clinical Procedure Guide Standard v1.0
Specialty	Orthopedic Surgery · Adult Reconstruction · Knee
Primary CPT® codes	27447 (TKA); 27446 (UKA); 27445 (hinge); 27486 / 27487 (revision); 27488 (prosthesis removal)
2026 regulatory context	CMS began phasing out the Inpatient Only list 01/01/2026; the mandatory TEAM episode model launched 01/01/2026 with knee replacement as a core episode
Setting	Hospital Inpatient (POS 21) · Hospital Outpatient (POS 22) · Ambulatory Surgery Center (POS 24)
Version / Date	1.0 · July 2026 (two-pass code audit applied at authoring)
Author	Pinky Maniri, MSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF · Certified in Healthcare A.I. Governance · Founder & Chief Executive Officer, GoHealthcare Practice Solutions

Contents

1. Evidence at a Glance2. Overview3. Relevant Anatomy (High-Level Overview)4. Clinical Indications5. Patient Selection6. Contraindications7. Conservative Treatment Requirements8. Imaging Requirements9. Medical Necessity10. Medicare Coverage, Site of Service, and the TEAM Model11. Commercial Payer Comparison12. Prior Authorization Workflow13. Documentation Requirements14. Common Prior Authorization Denials15. Appeal Strategies16. Coding & Billing Overview17. Implants, Devices, and System Considerations18. Clinical Documentation Checklist (Operative Note)19. Procedure Comparison20. GoHealthcare Clinical Insights21. GoHealthcare Leadership Perspective22. GoHealthcare Prior Authorization Insight23. GoHealthcare Case Study24. GoHealthcare Best Practices25. Common Mistakes26. Pearls and Pitfalls27. Frequently Asked Questions28. Key Takeaways29. Future Outlook30. References31. Reading Recommendations32. Related GoHealthcare Resources (Internal Links)33. Recommended Downloads34. Visual Recommendations35. Document History36. Educational Disclaimer

1

Evidence at a Glance

Knee arthroplasty is the highest-expenditure procedure in this library and the one under the most active payment-model pressure. Two things changed on January 1, 2026: CMS began dismantling the Inpatient Only list, and the mandatory Transforming Episode Accountability Model (TEAM) went live with lower extremity joint replacement as a core episode. Separately, eviCore's knee arthroplasty guideline was revised with coverage-limiting clinical changes effective March 7, 2026. Authorization teams working from 2025 assumptions are working from the wrong map.

Domain	Summary
Medicare NCD	No National Coverage Determination specific to knee arthroplasty. General "reasonable and necessary" standard applies (Social Security Act 1862(a)(1)(A)).
Medicare LCD / MAC	No dedicated national LCD. Traditional fee-for-service Medicare does not require prior authorization; medical review and site-of-service review apply.

Domain	Summary
IPO / ASC status	Total knee arthroplasty was removed from the Inpatient Only list effective 01/01/2018 and added to the Medicare ASC Covered Procedures List effective 01/01/2020. CMS began phasing out the IPO list entirely on 01/01/2026, with full elimination by 01/01/2029 and 285 predominantly musculoskeletal procedures removed for CY2026.
TEAM model	A mandatory five-year episode-based payment model running 01/01/2026 through 12/31/2030 across 188 metropolitan areas and roughly 741 hospitals. Lower Extremity Joint Replacement — including both inpatient and outpatient knee replacement — is one of five episode categories.
eviCore currency	CMM-311 (Knee Replacement/Arthroplasty) was revised with clinical changes that LIMIT coverage effective 03/07/2026. The Cigna commercial edition carries an effective date of 08/04/2026.
Prior authorization	Required by essentially all commercial plans and Medicare Advantage. The arthroplasty code family appears on every vendor PA list reviewed.
Evidence level	Strong. Knee arthroplasty is a well-established, high-satisfaction procedure for end-stage arthritis failing non-operative care.
Imaging	Weight-bearing radiographs establishing end-stage degenerative change are the determinative study. Non-weight-bearing films understate disease and weaken the request.
Conservative therapy	Documented, dated non-operative care is expected and is the most commonly deficient element.
Key documentation	Weight-bearing radiographic severity, functional impairment, dated conservative care, compartment involvement, alignment, and — where inpatient admission is planned — a prospective site-of-service rationale.
Typical approval driver	Radiographically confirmed end-stage arthritis with documented functional impairment after a dated conservative-care trial. Denials cluster around insufficient radiographic severity and incomplete conservative care.

2

Overview

Knee arthroplasty resurfaces the arthritic knee with prosthetic components. Total knee arthroplasty replaces both the medial and lateral tibiofemoral compartments, with or without patellar resurfacing. Unicompartmental knee arthroplasty replaces a single tibiofemoral compartment. Revision procedures replace one or both components of a failed prosthesis, and prosthesis removal without reimplantation is a distinct service, typically the first stage of a two-stage infection protocol.

Coverage of the procedure is well established. What has changed, and changed sharply in 2026, is the environment around it: site of service is now a documented clinical decision rather than a scheduling default, episode-based accountability extends 30 days past discharge for a large share of hospitals, and the dominant commercial guideline has tightened. This guide is organized around those pressures.

What changed on January 1, 2026

• The Inpatient Only list began phasing out. 285 predominantly musculoskeletal procedures came off for CY2026, with full elimination by 01/01/2029.

• TEAM went live. A mandatory episode model covering lower extremity joint replacement — inpatient and outpatient — with hospitals accountable for cost and quality across Medicare Parts A and B for 30 days after discharge.

• eviCore CMM-311 tightened. Revised with clinical changes that limit coverage, effective 03/07/2026.

3

Relevant Anatomy (High-Level Overview)

• Three compartments: medial tibiofemoral, lateral tibiofemoral, and patellofemoral. Which compartments are replaced determines the code — this is the central coding fact.

• Femoral condyles and tibial plateau: the surfaces resurfaced in both total and unicompartmental arthroplasty.

• Patella: may or may not be resurfaced in a total knee arthroplasty; the code descriptor accommodates both, so resurfacing does not change or add a code.

• Collateral and cruciate ligaments: their integrity determines implant constraint. Deficiency drives selection of posterior-stabilized, constrained, or hinged designs.

• Mechanical alignment: varus or valgus deformity influences candidacy for unicompartmental arthroplasty and drives operative planning.

• Bone stock: the determining variable in revision, where defects may require augments, cones, sleeves, or allograft.

4

Clinical Indications

• End-stage tricompartmental or bicompartmental osteoarthritis with pain and functional limitation refractory to documented non-operative care — the principal indication for total knee arthroplasty.

• Isolated single-compartment arthritis with preserved ligaments, acceptable alignment, and intact remaining compartments — the candidate profile for unicompartmental arthroplasty.

• Post-traumatic arthritis of the knee.

• Inflammatory arthropathy with joint destruction.

• Osteonecrosis of the femoral condyle or tibial plateau with secondary degenerative change.

• Failed prior arthroplasty with documented mode of failure — aseptic loosening, wear, instability, malalignment, stiffness, or periprosthetic infection.

• Periprosthetic infection requiring prosthesis removal, typically as the first stage of a staged protocol.

• Severe deformity or instability requiring constrained or hinged reconstruction.

5

Patient Selection

Variable	Why it matters operationally
Radiographic severity	Weight-bearing films establishing end-stage change are decisive. "Pain with moderate radiographic change" is the most common substantive denial.
Compartment involvement	Determines total versus unicompartmental, and therefore the code. A multi-compartment diagnosis submitted with a unicompartmental code creates a clinical logic conflict that flags the claim.
Functional impairment	Effect on ambulation, stairs, sleep, and ADLs — the substance of medical necessity.
Conservative care	Dated trial with documented outcome. The most frequently deficient element in otherwise strong requests.
Alignment and ligament integrity	Determines unicompartmental candidacy and implant constraint.
Site-of-service suitability	Comorbidities, anesthesia risk, home support, and expected recovery now bear directly on whether an inpatient stay is defensible.
Episode-model context	For hospitals in TEAM, 30-day post-discharge cost and quality accountability makes discharge planning, PROM capture, and readmission avoidance part of the selection conversation.
Medical optimization	Glycemic control, weight, smoking status, and infection risk factors are commonly addressed in criteria sets and in episode performance.

6

Contraindications

• Active local or systemic infection (except where prosthesis removal is itself the infection treatment).

• Medical instability precluding safe anesthesia and surgery.

• Extensor mechanism insufficiency or profound quadriceps deficiency without a reconstruction plan.

• Neuropathic (Charcot) arthropathy.

• Radiographically mild or moderate disease where imaging does not support end-stage arthritis — a contraindication and a predictable denial.

• For unicompartmental arthroplasty specifically: inflammatory arthropathy, significant ligamentous deficiency, fixed deformity, or disease in the remaining compartments.

• Inability or unwillingness to participate in post-operative rehabilitation.

7

Conservative Treatment Requirements

Element	What payers look for
Duration	A documented, dated non-operative trial. Requirements vary by vendor and plan; capture start and end dates rather than a general assertion.
Physical therapy	A structured quadriceps and hip-strengthening program with dates, frequency, and functional response.
Pharmacologic care	NSAIDs or analgesics as tolerated, with activity modification and joint-conservation counseling now referenced in 2026 UM policy language.
Injection	Intra-articular corticosteroid or viscosupplementation where clinically appropriate and covered, with documented response and date.
Assistive devices and weight management	Frequently addressed in criteria sets; document what was tried and the response.
Recognized exceptions	Periprosthetic infection, periprosthetic fracture, failed prior arthroplasty, and tumor are not subject to the elective conservative-care pathway. Label such requests explicitly.
Documented failure	A statement that conservative care was completed and did not provide durable relief, with the persistent functional deficit described.

8

Imaging Requirements

• Weight-bearing radiographs are the determinative study and should be quoted directly. They establish joint space narrowing, subchondral sclerosis, cysts, osteophytes, and alignment. A non-weight-bearing film understates disease and weakens your own request.

• Compartment-specific findings matter: unicompartmental arthroplasty requires documentation that the remaining compartments are preserved.

• Long-leg alignment films where deformity is significant or unicompartmental arthroplasty is contemplated.

• For revision: radiographs and often CT to assess component position, loosening, osteolysis, and bone stock; laboratory and aspiration workup where infection is suspected.

• MRI is generally not required for arthroplasty candidacy and does not substitute for weight-bearing radiographs.

9

Medical Necessity

Pillar	Documentation that demonstrates it
Radiographic severity	Weight-bearing findings quoted, establishing end-stage change in the compartments to be replaced.
Functional impairment	Pain scores, ambulation distance, stair use, sleep disturbance, and assistive device use.
Conservative care	Dated trial with documented outcome, or a stated exception.
Examination findings	Range of motion, deformity, effusion, ligament stability, and gait.
Compartment logic	For unicompartmental requests, explicit documentation that the other compartments are preserved.
Site of service	Where inpatient admission is planned, prospectively documented clinical rationale.

10

Medicare Coverage, Site of Service, and the TEAM Model

Coverage basics

• No NCD and no dedicated national LCD govern knee arthroplasty; coverage rests on the general reasonable-and-necessary standard with MAC medical review.

• Traditional Medicare requires no prior authorization. Medicare Advantage plans generally do, and commonly delegate to eviCore, Carelon, Cohere, Evolent/NIA, or TurningPoint.

• Inpatient knee arthroplasty groups to a major joint replacement MS-DRG; confirm the current assignment, which also functions as the anchor event for episode-based models.

Site of service

• Total knee arthroplasty came off the Inpatient Only list effective 01/01/2018 and was added to the Medicare ASC Covered Procedures List effective 01/01/2020. It has therefore been through this transition ahead of most orthopedic procedures.

• CMS began phasing out the IPO list entirely on 01/01/2026, with 285 predominantly musculoskeletal procedures removed for CY2026 and full elimination by 01/01/2029. Revision arthroplasty codes historically carried inpatient-only status; their current status must be confirmed against the CY2026 addenda rather than assumed from prior-year references.

• CMS has been explicit that removal from the IPO list does not mean a procedure must be performed outpatient. Physicians retain site-of-service judgment — but an inpatient admission now requires prospectively documented clinical rationale, and commercial and Medicare Advantage plans are expected to scrutinize inpatient claims.

The TEAM model

• TEAM is a mandatory, five-year, episode-based payment model running 01/01/2026 through 12/31/2030, implemented across 188 metropolitan areas and roughly 741 hospitals, encompassing about a quarter of Medicare beneficiaries.

• Lower Extremity Joint Replacement is one of five episode categories, alongside surgical hip/femur fracture treatment, spinal fusion, coronary artery bypass graft, and major bowel procedures. LEJR includes both inpatient and outpatient hip and knee replacement.

• Episodes are triggered by an anchor event and extend 30 days after discharge, with the hospital accountable for cost and quality across Medicare Parts A and B during that window.

• Participants continue to bill traditional fee-for-service. CMS sets target prices; hospitals may earn reconciliation payments or owe repayments, adjusted by a Composite Quality Score, with stop-gain and stop-loss limits. Three participation tracks provide graduated risk.

• Patient-reported outcome measures are required for LEJR episodes, using the KOOS Jr for knee (and HOOS Jr for hip), collected pre-operatively within a defined window and again post-operatively. Failure to capture PROMs at the required rate directly affects quality scoring.

• A skilled nursing facility 3-day rule waiver applies. CMS implemented a waiver, effective 01/01/2026, allowing TEAM participants to discharge eligible patients to a qualified SNF or swing-bed provider without the usual 3-day inpatient stay requirement, identified on SNF claims by demonstration code A9. The SNF admission must occur no later than 30 days after discharge. This directly affects discharge planning and post-acute cost, which is where episode performance is won or lost.

• Performance Year 1 provides a glide path. Track 1 carries no downside risk for the first year for all participants, and up to three years for safety net hospitals, with higher-risk tracks available thereafter. Target prices are risk-adjusted using regional baseline spending across the nine U.S. census divisions.

• The model is codified at 42 CFR Part 512, Subpart E. It was finalized in the FY2025 IPPS final rule and updated in the FY2026 IPPS final rule, which among other changes removed the hospital health equity plan and Health-Related Social Needs screening and reporting requirements.

• TEAM's design was informed by the Comprehensive Care for Joint Replacement model, which CMS reports generated $112.7 million in Medicare savings across 2021–2023 while maintaining quality. In April 2026 CMS proposed a nationwide expansion of the CJR model, excluding hospitals already participating in TEAM.

Why TEAM belongs in an authorization guide

Episode accountability changes what "a successful case" means. Under fee-for-service alone, an approved authorization and a paid claim complete the transaction. Under TEAM, the hospital remains financially accountable for 30 days past discharge — which pulls discharge disposition, post-acute utilization, readmission avoidance, and PROM capture into the same operational conversation as prior authorization.

Practically, MSK service lines in TEAM markets should ensure that pre-operative workflows already capture the KOOS Jr, that site-of-service and discharge planning decisions are documented prospectively, and that medical optimization occurs before scheduling rather than after. These are the same disciplines that produce clean authorizations — the episode model simply raises the cost of neglecting them.

11

Commercial Payer Comparison

Payer / vendor	How knee arthroplasty is managed (summary)
eviCore by Evernorth	CMM-311 (Knee Replacement/Arthroplasty) is the governing guideline, distinct from CMM-312 which covers knee arthroscopic and open non-arthroplasty surgery. Currency note: eviCore's February 2026 update records that CMM-311 was revised with clinical changes that LIMIT coverage, effective 03/07/2026 — alongside CMM-313 (Hip Replacement) and CMM-315 (Shoulder Surgery). The Cigna commercial edition carries an effective date of 08/04/2026. Working from a 2025 version of this guideline will produce avoidable denials.
Carelon Medical Benefits Mgmt	Joint Surgery guideline and Musculoskeletal Program code list carry the knee arthroplasty family.
Cohere Health	MSK surgical authorization platform used by several plans including Humana lines; radiographic severity, conservative care, and functional impairment are the determinative fields.
Evolent / NIA	Knee arthroplasty clinical guidelines with UM code matrices defining allowable billed groupings.
TurningPoint	Delegated surgical PA on many plans, with 2026 MSK policy updates affecting knee criteria and non-operative treatment requirements.
UnitedHealthcare / Aetna / Cigna / Humana	Each maintains knee arthroplasty policy or delegates; Cigna managed lines run through eviCore CMM-311. Several plans maintain separate policies classifying computer-assisted navigation and robotic assistance as not separately reimbursable.
Blue Cross Blue Shield plans	Vary by licensee; delegation may run to Carelon, eviCore, TurningPoint, or HealthHelp. Several publish their own navigation and robotics policies. Verify per plan, per cycle.

12

Prior Authorization Workflow

• 1. Eligibility & vendor identification. Confirm the vendor and, critically, the guideline version in force — the dominant commercial criteria set changed in March 2026.

• 2. Obtain weight-bearing radiographs and quote the findings. Do not submit on examination or MRI alone.

• 3. Establish compartment involvement and confirm it matches the planned procedure and the diagnosis codes.

• 4. Compile dated conservative care with outcomes, or state a recognized exception.

• 5. Document functional impairment specifically — ambulation distance, stairs, sleep, assistive devices.

• 6. Determine and document site of service prospectively.

• 7. In TEAM markets, confirm the episode workflow is engaged — pre-operative KOOS Jr captured, medical optimization completed, discharge plan drafted.

• 8. Verify facility authorization separately and confirm implant economics where an ASC pathway is contemplated.

• 9. Submit, track, confirm. Record authorization number, approved codes, approved site of service, and validity window.

13

Documentation Requirements

• Pain score, duration, and functional impairment (ambulation, stairs, sleep, assistive devices)

• Range of motion, deformity, effusion, and ligament stability on examination

• Weight-bearing radiographic findings quoted, with compartments specified

• Alignment assessment, and long-leg films where deformity is significant

• For unicompartmental requests: explicit documentation that remaining compartments are preserved

• Dated conservative treatment history with documented outcome, OR a stated exception

• Medical optimization status where relevant to criteria

• Laterality clearly documented

• Prior ipsilateral knee surgery or arthroplasty, with implant details if revision

• For revision: mode of failure with imaging and, where infection is suspected, laboratory and aspiration workup

• Site-of-service determination with clinical rationale where inpatient admission is planned

• In TEAM markets: pre-operative KOOS Jr captured within the required window

14

Common Prior Authorization Denials

Denial reason	Root cause / prevention
Radiographic severity insufficient	Imaging shows moderate change while the request asserts end-stage disease, or films were non-weight-bearing. Prevention: obtain weight-bearing films and quote them verbatim.
Conservative care not documented	No dated trial. Prevention: capture dates and outcomes, or state a recognized exception.
Outdated guideline assumptions	Request built against pre-March-2026 criteria. Prevention: confirm the guideline version in force each cycle.
Compartment logic conflict	Unicompartmental code submitted with a multi-compartment osteoarthritis diagnosis. Prevention: align the diagnosis, the imaging, and the planned procedure.
Functional impairment not specific	Generic pain description. Prevention: quantify ambulation, stairs, sleep, and device use.
Site-of-service denial	Inpatient admission without prospective clinical rationale following IPO removal. Prevention: document comorbidities, anesthesia risk, and recovery needs before surgery.
Facility authorization mismatch	Professional side authorized, facility or ASC not, or approved site differs from scheduled site. Prevention: verify both.
Navigation or robotics billed	Computer-assisted or robotic components reported separately. Prevention: understand that most payers classify these as not separately reimbursable.

15

Appeal Strategies

• Answer the specific criterion cited; arthroplasty criteria are itemized and respond well to point-by-point rebuttal.

• For radiographic-severity denials, supply the full weight-bearing radiology report. A narrative impression rarely overturns the denial, and non-weight-bearing films will not either.

• Confirm which guideline version the reviewer applied. Where a denial reflects criteria that changed in March 2026, or where the reviewer applied the wrong guideline, say so explicitly.

• For compartment-logic denials, correct the diagnosis coding or the procedure selection rather than arguing the conflict.

• For site-of-service denials, supply the prospectively documented rationale; retrospective justification is materially weaker.

• For navigation and robotics denials, recognize these are policy-based non-coverage determinations rather than documentation failures and are generally not winnable on appeal.

• Preserve internal and external appeal deadlines; medical-necessity disputes qualify for independent external review.

16

Coding & Billing Overview

Operational overview for authorization and revenue-cycle teams. Descriptors verified against current CPT® references and published payer and manufacturer coding materials. Detailed reimbursement methodology, APC assignment, and episode financial modeling belong in the GoHealthcare Revenue Cycle Knowledge Center.

Arthroplasty Code Family (verified descriptors)

CPT®	Descriptor	Operational notes
27447	Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)	Total knee arthroplasty. Patellar resurfacing is inside the descriptor and is NOT separately reportable. Implant constraint (standard vs. posterior-stabilized vs. constrained) does not change the primary code.
27446	Arthroplasty, knee, condyle and plateau; medial OR lateral compartment	Unicompartmental arthroplasty of a single tibiofemoral compartment. Reporting 27447 where only one compartment was replaced is upcoding; the operative note must state which compartments were addressed.
27445	Arthroplasty, knee, hinge prosthesis	Constrained hinge implant, typically for severe instability or bone loss.
27486	Revision of total knee arthroplasty, with or without allograft; 1 component	Revision of ONE component. Allograft is included in the descriptor — do not report separately.
27487	Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component	Revision of BOTH components. Allograft included.
27488	Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee	Removal without reimplantation — typically the first stage of a two-stage infection protocol. Spacer insertion is included. Do not report alongside a revision code where a new prosthesis was implanted in the same session.
What is already inside 27447 Published coding guidance indicates that 27447 includes the associated intra-operative work required to implant the prosthesis — including synovectomy, osteophyte removal, and minimal bone grafting performed in the same session. These should not be reported separately. Patellar resurfacing is likewise inside the descriptor.

Conversion Coding — Contested Guidance

Conversion of a unicompartmental or patellofemoral arthroplasty to a total knee arthroplasty has no dedicated conversion code, and published guidance offers more than one defensible answer. Practices should adopt a documented position rather than deciding case by case.

Published position	Rationale
Report 27447	The procedure constitutes a total knee arthroplasty regardless of what was previously implanted, and is therefore not a revision of a total knee arthroplasty. Attributed to AAPC guidance.
Report 27447 with modifier 22	Same code selection, with modifier 22 capturing the increased work of removing the prior implant, where primary implants were used. Attributed to AAOS guidance.
Report 27487 with modifier 52	Treats the conversion within the revision family while reducing for work not performed. Attributed to AMA guidance via published coding advisories.
Common thread	All positions require the operative note to document clearly what was removed, what was implanted, and whether primary or revision components were used. Without that, no position can be supported.

Note separately that patellofemoral-only arthroplasty is not clearly described by 27446, whose descriptor addresses the condyle and plateau. Confirm the appropriate reporting for a patellofemoral-only procedure against current guidance and the payer's position rather than assuming a compartment code applies.

Computer-Assisted Navigation and Robotic Assistance

Code	Descriptor	Coverage posture
20985	Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (list separately in addition to code for primary procedure)	Active Category I add-on code. Note that companion codes 20986 and 20987 were deleted effective 12/31/2008; 20985 was not.
0054T	Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on fluoroscopic images (list separately)	Category III.
0055T	Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image guidance based on CT/MRI images (list separately)	Category III.
Navigation and robotics are widely non-covered Multiple national and Blue Cross Blue Shield plan policies classify computer-assisted navigation for orthopedic procedures as investigational, and state that 20985, 0054T, and 0055T are not covered and not separately reimbursable. Payer policies also commonly treat intra-operative sensors for implant stability during knee arthroplasty as incidental to the primary procedure and not separately reimbursable. The operational implication is that robotic and navigated knee arthroplasty are generally performed for clinical and workflow reasons rather than incremental professional reimbursement, and the associated facility cost sits inside the arthroplasty payment — a material consideration for ASC feasibility and, in TEAM markets, for episode cost performance.

Common ICD-10-CM Diagnosis Codes (FY2026)

ICD-10-CM	Description	Coding note
M17.11 / M17.12	Unilateral primary osteoarthritis, right / left knee	The principal indication code for elective total knee arthroplasty.
M17.0	Bilateral primary osteoarthritis of knee	Where bilateral disease is documented.
M17.2- / M17.3-	Bilateral / unilateral post-traumatic osteoarthritis of knee	Where arthritis follows documented prior trauma; select the specific code with laterality.
M17.4- / M17.5	Other secondary osteoarthritis of knee / other osteoarthritis of knee	Secondary and other degenerative presentations.
M23.- family	Internal derangement of knee	Concurrent meniscal or ligamentous derangement where documented; not a substitute for an arthritis code.
Z96.65- family	Presence of artificial knee joint, with laterality	Status code for the revision and post-arthroplasty context. Note that presence-of-implant status codes are not acceptable as a principal diagnosis.
T84.0- family	Mechanical complication of internal joint prosthesis	The revision driver — loosening, wear, dislocation, malposition, breakage. ICD-10-CM instructs an additional code to identify the joint (Z96.6-).
T84.5- family	Infection and inflammatory reaction due to internal joint prosthesis	Periprosthetic joint infection; supports prosthesis removal and staged protocols.
M25.561 / M25.562	Pain in right / left knee	Non-specific; never the sole support for arthroplasty.

Compartment logic matters diagnostically as well as procedurally. Submitting a multi-compartment osteoarthritis diagnosis alongside a unicompartmental arthroplasty code creates a clinical logic conflict that flags the claim for medical-necessity review. Align the diagnosis, the imaging, and the procedure.

Modifiers, Place of Service, and Facility Considerations

Item	Guidance
RT / LT	Laterality; append per payer requirement.
50	Bilateral procedure, where both knees are replaced in the same session and the payer requires it.
22	Increased procedural services — the recognized mechanism for conversion cases under certain published positions, and for genuinely atypical complexity. Requires operative-note support.
52	Reduced services — appears in published guidance for certain conversion scenarios where a revision code overstates the work.
59 / X{EPSU}	Distinct procedural service. Verify the current NCCI modifier indicator before use.
AS / 80 / 81 / 82	Assistant-at-surgery, when documented and supported.
POS 21 / 22 / 24	Inpatient / on-campus hospital outpatient / ASC. All three are realistic pathways; the authorization must match the rendered setting.
Currency warning NCCI procedure-to-procedure edits and modifier indicators are republished quarterly, and OPPS and ASC status indicators change annually with the final rule. With the Inpatient Only list actively phasing out through 2029, status assignments for arthroplasty codes — particularly revision codes — must be confirmed against the current addenda rather than prior-year vendor coding guides.

17

Implants, Devices, and System Considerations

Knee arthroplasty is implant-intensive, and implant cost is the dominant variable in both ASC feasibility and episode cost performance. Principal manufacturers include Stryker, Zimmer Biomet, DePuy Synthes, Smith+Nephew, Exactech, and Enovis/DJO.

• CPT® does not vary by manufacturer, implant design, or constraint level. Cruciate-retaining, posterior-stabilized, and constrained designs all report under the primary code; a hinge prosthesis is the exception at 27445.

• Robotic platforms and navigation systems add facility cost without generating separately reimbursable professional revenue under most policies. Model this explicitly before adopting.

• Revision constructs — augments, metaphyseal cones and sleeves, stems, and allograft — drive substantial cost variation. Allograft is contemplated within 27486 and 27487 by descriptor and is not separately reported.

• Antibiotic spacers used in staged infection protocols are contemplated within 27488.

• Implant cost drives site of service. A case can be clinically appropriate for an ASC and economically infeasible for a given construct; facility and surgeon should align before the site is confirmed.

• In TEAM markets, implant selection is an episode cost variable, since the hospital carries accountability for the episode against a target price.

• For any novel implant or adjunct technology, verify FDA status, coding, and payer coverage as three independent determinations.

18

Clinical Documentation Checklist (Operative Note)

• Laterality and approach

• Which compartments were replaced — the fact that distinguishes 27447 from 27446

• Whether the patella was resurfaced (included in 27447, not separately reported)

• Components implanted with manufacturer, type, size, and constraint level

• Alignment achieved and any deformity correction performed

• For conversion: what prior implant was removed, what was implanted, and whether primary or revision components were used

• For revision: mode of failure, components removed, components retained, augments/cones/stems used, and any allograft

• For prosthesis removal: whether a spacer was inserted (included in 27488)

• Any use of computer-assisted navigation or robotic assistance, and the modality

• Findings supporting the reported diagnosis code, including compartment involvement

19

Procedure Comparison

Pathway	Typical patient	Code	Authorization emphasis
Total knee arthroplasty	End-stage bi- or tricompartmental arthritis	27447	Weight-bearing radiographs + conservative care
Unicompartmental arthroplasty	Isolated single-compartment disease, intact ligaments	27446	Preserved remaining compartments documented
Hinge arthroplasty	Severe instability or bone loss	27445	Constraint rationale documented
Revision, one component	Isolated component failure	27486	Mode of failure documented
Revision, both components	Global failure	27487	Mode of failure documented
Prosthesis removal	Periprosthetic infection, staged protocol	27488	Infection workup; staged plan
UKA to TKA conversion	Failed or progressed unicompartmental	Contested (see coding section)	Document components removed and implanted

Pathway	Typical patient	Code	Authorization emphasis
Non-arthroplasty options	Earlier-stage disease	Arthroscopic codes	Different guideline family (CMM-312)

20

GoHealthcare Clinical Insights

Operational recommendations from MSK authorization practice

• Require weight-bearing radiographs on every arthroplasty request and quote the findings verbatim. This is the single highest-yield control in the procedure.

• Verify the guideline version in force before building the request — the dominant commercial knee arthroplasty criteria set tightened in March 2026.

• Align diagnosis, imaging, and procedure on compartment involvement; a unicompartmental code with a multi-compartment diagnosis flags the claim.

• Treat site of service as a documented clinical decision with a prospective rationale.

• Verify facility and professional authorization separately and confirm the approved site matches the scheduled site.

• Do not bill navigation or robotics; most policies classify them as investigational and not separately reimbursable.

• Adopt a written organizational position on conversion coding rather than deciding case by case.

• In TEAM markets, integrate pre-operative KOOS Jr capture and discharge planning into the same workflow as authorization.

21

GoHealthcare Leadership Perspective

Executive view: three simultaneous pressures

Knee arthroplasty entered 2026 facing three changes at once. The Inpatient Only list began dismantling, making site of service a documented clinical decision with denial exposure in both directions. The mandatory TEAM model extended hospital accountability 30 days past discharge for roughly a quarter of Medicare beneficiaries. And the dominant commercial criteria set tightened. Any one of these would warrant a workflow review; together they make 2025-vintage assumptions actively costly.

The encouraging feature is that all three reward the same disciplines. Weight-bearing imaging and complete conservative-care documentation satisfy tightened criteria. Prospective site-of-service determination satisfies both the IPO transition and the episode model. Pre-operative medical optimization improves authorization strength, episode cost performance, and quality scores simultaneously. Service lines that build these once benefit across all three pressures; those that treat authorization, site of service, and episode performance as separate workstreams pay three times for the same underlying gaps.

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GoHealthcare Prior Authorization Insight

What we see that payer policies do not spell out

• Weight-bearing films decide these cases. A non-weight-bearing radiograph understates joint space and weakens your own request.

• Guideline version is now a live variable. CMM-311 tightened effective 03/07/2026; a request built on the prior version may fail on criteria that did not previously exist.

• Compartment logic is checked. A unicompartmental code with a multi-compartment diagnosis is an automatic flag.

• Patella resurfacing is inside 27447. So are synovectomy, osteophyte removal, and minimal bone grafting.

• Conversion coding has three published answers. Pick one, document it, and make sure the operative note supports it.

• Navigation and robotics denials are policy, not documentation. They are generally not winnable on appeal.

• In TEAM markets the case does not end at discharge. Thirty days of cost and quality accountability follow, and PROM capture affects scoring.

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GoHealthcare Case Study

Educational scenario — details are illustrative and do not identify any actual patient or organization.

Clinical Scenario

A 69-year-old patient with two years of progressive right knee pain presents after physical therapy, NSAIDs, and two intra-articular injections. Ambulation is limited to roughly one block, stairs require a rail, and night pain disturbs sleep. Examination shows a varus deformity, an effusion, and range of motion from 5 to 105 degrees. The surgeon plans a total knee arthroplasty using a robotic platform, and the practice schedules the case as an inpatient admission by long-standing habit. The hospital is located in a TEAM-mandated metropolitan area.

Documentation and Coding Challenges

The authorization packet included only non-weight-bearing radiographs, described the findings as "advanced degenerative changes" without quoting the report, and listed conservative care without dates. The request was built from the practice's 2025 criteria checklist. The billing team planned to report the robotic assistance separately. No pre-operative KOOS Jr had been collected, and no site-of-service rationale was documented.

Barriers

The request pended on radiographic severity: without weight-bearing films the reviewer could not confirm joint space loss. The 2025 checklist had omitted criteria added in the March 2026 guideline revision. Separately, the robotic component would have been denied as not separately reimbursable, the inpatient admission was exposed following the procedure's removal from the Inpatient Only list, and the missing KOOS Jr would count against the hospital's episode quality score regardless of the authorization outcome.

Payer and Program Considerations

The plan did not dispute that arthroplasty was appropriate in principle. Its concerns were evidentiary. The episode-model exposure was entirely separate from the authorization and would not have surfaced through the authorization workflow at all.

Resolution Strategy

• Obtained weight-bearing radiographs and quoted the joint space and alignment findings verbatim.

• Rebuilt the request against the current guideline version, addressing the criteria added in the March 2026 revision.

• Added dated conservative care with documented outcomes and quantified functional impairment.

• Conducted and documented a prospective site-of-service assessment; comorbidities and limited home support supported admission, and the rationale was recorded pre-operatively.

• Removed the robotic assistance from anticipated billing, documenting its use in the operative note without separate reporting.

• Captured the pre-operative KOOS Jr within the required window and engaged the discharge planning workflow at scheduling rather than post-operatively.

Outcome

The arthroplasty was approved at the documented site of service without a peer-to-peer. The claim matched the authorization, no navigation denial arose, and the episode began with the required patient-reported outcome captured.

Lessons Learned

• Weight-bearing radiographs are not a formality; they are the evidence the criteria are written around.

• A criteria checklist is a dated artifact. When the guideline moves, the checklist must move with it.

• In episode markets, authorization workflow and episode workflow must be the same workflow — otherwise quality and cost exposure accrues invisibly.

• Knowing a technology is non-covered before the case converts a denial into a documented clinical choice.

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GoHealthcare Best Practices

• Require weight-bearing radiographs and quote them verbatim on every request.

• Re-verify the governing guideline version each authorization cycle and date your internal checklists.

• Align diagnosis, imaging, and procedure on compartment involvement before submission.

• Document site-of-service rationale prospectively for every arthroplasty case.

• Verify professional and facility authorization separately and match the approved site.

• Adopt and document an organizational position on conversion coding.

• Exclude navigation and robotics from billing absent a payer policy to the contrary.

• In TEAM markets, integrate KOOS Jr capture, medical optimization, and discharge planning into the pre-authorization workflow.

• Confirm arthroplasty status indicators against current CMS addenda as the IPO list continues to phase out.

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Common Mistakes

• Submitting non-weight-bearing radiographs on an arthroplasty request.

• Reporting 27447 when only one compartment was replaced.

• Reporting patellar resurfacing separately with 27447; it is inside the descriptor.

• Reporting synovectomy, osteophyte removal, or minimal bone grafting separately with a primary arthroplasty.

• Reporting allograft separately with 27486 or 27487, which include it by descriptor.

• Reporting 27488 alongside a revision code where a new prosthesis was implanted in the same session.

• Submitting a multi-compartment osteoarthritis diagnosis with a unicompartmental arthroplasty code.

• Billing 20985, 0054T, or 0055T where the payer classifies navigation as investigational and non-reimbursable.

• Admitting as an inpatient without prospectively documented clinical rationale following IPO removal.

• Building requests from a criteria checklist that predates the March 2026 guideline revision.

• Assuming a revision code carries prior-year OPPS or ASC status without checking the current addenda.

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Pearls and Pitfalls

Pearls	Pitfalls
Quote weight-bearing radiographic findings.	Characterizing imaging as "advanced" without support.
Date and version your criteria checklists.	Working from last year's checklist after a revision.
Match compartment logic across dx, imaging, code.	Unicompartmental code with bicompartmental dx.
Document site of service prospectively.	Admitting by habit after IPO removal.
Settle conversion coding in writing.	Case-by-case guesswork across three positions.
Treat episode and authorization as one workflow.	Discovering missing PROMs after discharge.

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Frequently Asked Questions

Q1. What code reports a total knee arthroplasty? 27447 (Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing). Both tibiofemoral compartments must be replaced.

Q2. What code reports a unicompartmental knee arthroplasty? 27446 (Arthroplasty, knee, condyle and plateau; medial OR lateral compartment), for replacement of a single tibiofemoral compartment. Reporting 27447 where only one compartment was replaced is upcoding.

Q3. Is patellar resurfacing separately billable with 27447? No. It is inside the code descriptor, which reads "with or without patella resurfacing."

Q4. What else is included in 27447? Published guidance indicates the associated intra-operative work required to implant the prosthesis, including synovectomy, osteophyte removal, and minimal bone grafting performed in the same session.

Q5. How are revisions coded? 27486 for revision of one component; 27487 for revision of the femoral and entire tibial component. Both include allograft when performed — do not report allograft separately.

Q6. What code applies when the prosthesis is removed without reimplantation? 27488, which includes methylmethacrylate and spacer insertion when performed. It is typically the first stage of a two-stage infection protocol and should not be reported alongside a revision code where a new prosthesis was implanted in the same session.

Q7. How is a conversion from unicompartmental to total knee coded? There is no dedicated conversion code and published guidance offers three positions: 27447 alone; 27447 with modifier 22; or 27487 with modifier 52. All require the operative note to document what was removed, what was implanted, and whether primary or revision components were used. Adopt a documented organizational position.

Q8. How is patellofemoral-only arthroplasty coded? 27446 describes the condyle and plateau, so a patellofemoral-only procedure is not clearly described by it. Confirm the appropriate reporting against current guidance and the payer's position rather than assuming a compartment code applies.

Q9. Can computer-assisted navigation or robotic assistance be billed? Generally no. 20985 (image-less), 0054T (fluoroscopic guidance), and 0055T (CT/MRI guidance) exist, but multiple national and Blue Cross Blue Shield plan policies classify computer-assisted navigation as investigational and state these codes are not covered or separately reimbursable.

Q10. Were any navigation codes deleted? Yes — 20986 and 20987 were deleted effective 12/31/2008. 20985 remains active, and 0054T and 0055T were subsequently re-added.

Q11. Is an intra-operative implant stability sensor separately reimbursable? Payer policy commonly treats it as incidental to the primary procedure and not separately reimbursable.

Q12. Is knee arthroplasty still inpatient-only for Medicare? No. Total knee arthroplasty was removed from the Inpatient Only list effective 01/01/2018 and added to the ASC Covered Procedures List effective 01/01/2020. CMS began phasing out the IPO list entirely on 01/01/2026, with full elimination by 01/01/2029.

Q13. Does removal from the IPO list mean the procedure must be outpatient? No. CMS has been explicit that removal does not identify a procedure as appropriate only for outpatient care, and physicians retain site-of-service judgment. However, inpatient admission now requires prospectively documented clinical rationale.

Q14. What is the TEAM model? The Transforming Episode Accountability Model — a mandatory, five-year, episode-based payment model running 01/01/2026 through 12/31/2030 across 188 metropolitan areas and roughly 741 hospitals. Lower Extremity Joint Replacement, including inpatient and outpatient knee replacement, is one of five episode categories.

Q15. How long does a TEAM episode last? The episode is triggered by an anchor event and extends 30 days after discharge, with the hospital accountable for cost and quality across Medicare Parts A and B during that window.

Q16. Does TEAM change how we bill? No. Participants continue to bill traditional fee-for-service. CMS sets target prices and reconciles afterward, with adjustments based on a Composite Quality Score and stop-gain and stop-loss limits.

Q17. What patient-reported outcome measure applies to knee episodes? The KOOS Jr for knee replacement (and HOOS Jr for hip), collected pre-operatively within a defined window and again post-operatively. Capture rates affect quality scoring.

Q18. Does TEAM change post-acute discharge rules? Yes. CMS implemented a skilled nursing facility 3-day rule waiver for TEAM participants effective 01/01/2026, allowing discharge of eligible patients to a qualified SNF or swing-bed provider without the usual 3-day inpatient stay, identified by demonstration code A9. The SNF admission must occur no later than 30 days after discharge.

Q19. Is there downside risk in the first year of TEAM? Track 1 carries no downside risk for the first performance year for all participants, and up to three years for safety net hospitals. Higher-risk tracks with greater reward are available thereafter.

Q20. Has the governing commercial guideline changed recently? Yes. eviCore's February 2026 update records that CMM-311 (Knee Replacement/Arthroplasty) was revised with clinical changes that limit coverage, effective 03/07/2026. Verify the version in force before building a request.

Q21. What imaging is expected? Weight-bearing radiographs establishing end-stage degenerative change are determinative, with long-leg alignment films where deformity is significant. MRI does not substitute.

Q22. Why was our unicompartmental request flagged? Frequently because the submitted diagnosis described multi-compartment osteoarthritis while the requested code addressed a single compartment — a clinical logic conflict. Align the diagnosis, imaging, and procedure.

Q23. Does traditional Medicare require prior authorization? No. There is no NCD or dedicated LCD, and knee arthroplasty is not in the OPD prior-authorization program. Medicare Advantage plans generally do require prior authorization.

Q24. Where does detailed reimbursement analysis belong? APC assignment, payment rates, fee schedules, NCCI/MUE tables, implant margin, and episode financial modeling belong in the GoHealthcare Revenue Cycle Knowledge Center, not in this operational guide.

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Key Takeaways

• 27447 requires both tibiofemoral compartments; 27446 is a single compartment. The operative note must state which.

• Patella resurfacing, synovectomy, osteophyte removal, and minimal bone grafting are inside the primary arthroplasty code.

• 27486/27487 include allograft; 27488 includes spacer insertion.

• Conversion from unicompartmental to total has three published coding positions — adopt one and document it.

• Navigation and robotics codes exist but are widely classified as investigational and non-reimbursable.

• TKA left the IPO list in 2018 and joined the ASC list in 2020; the IPO list itself is now phasing out through 2029.

• TEAM launched 01/01/2026 as a mandatory episode model with 30-day post-discharge accountability and required KOOS Jr capture.

• eviCore CMM-311 tightened effective 03/07/2026 — verify the guideline version in force.

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Future Outlook

• The IPO phase-out continues through 01/01/2029, progressively bringing revision arthroplasty and other complex procedures into outpatient payment eligibility.

• Episode-based accountability is expanding rather than contracting; CMS proposed a nationwide expansion of the Comprehensive Care for Joint Replacement model in April 2026, excluding hospitals already in TEAM.

• ASC migration of knee arthroplasty will continue, with implant cost and patient selection as the limiting variables.

• Commercial arthroplasty criteria are tightening; expect continued emphasis on radiographic severity thresholds and medical optimization.

• Robotic and navigated arthroplasty adoption will continue on clinical and workflow grounds rather than reimbursement, keeping cost inside the episode.

• Patient-reported outcome capture will become routine infrastructure rather than a program-specific requirement.

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References

• Centers for Medicare & Medicaid Services (CMS). Transforming Episode Accountability Model (TEAM) — model overview and fact sheet. Website: https://www.cms.gov/files/document/team-model-fs.pdf

• Electronic Code of Federal Regulations. 42 CFR Part 512, Subpart E — Transforming Episode Accountability Model (TEAM). Website: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-H/part-512/subpart-E

• Centers for Medicare & Medicaid Services (CMS). MLN Matters MM14098 — Implementing the Transforming Episode Accountability Model: Skilled Nursing Facility 3-Day Rule Waiver, effective January 1, 2026. Website: https://www.cms.gov/training-education/medicare-learning-network

• Centers for Medicare & Medicaid Services (CMS). Innovation Insight: Comprehensive Care for Joint Replacement (CJR) Model Generates Savings to Medicare. Website: https://www.cms.gov/priorities/innovation/innovation-insight-comprehensive-care-joint-replacement-cjr-model-generates-savings-medicare

• Centers for Medicare & Medicaid Services (CMS). CY2026 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule, including Inpatient Only list phase-out and ASC Covered Procedures List revisions. Website: https://www.cms.gov

• Centers for Medicare & Medicaid Services (CMS). Medicare Coverage Database (NCDs, LCDs, Articles). Website: https://www.cms.gov/medicare-coverage-database

• Centers for Medicare & Medicaid Services (CMS). National Correct Coding Initiative (NCCI) Policy Manual and quarterly PTP edit files. Website: https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits

• American Medical Association. Current Procedural Terminology (CPT®) and CPT® Assistant. Website: https://www.ama-assn.org

• American Academy of Orthopaedic Surgeons (AAOS). Clinical practice guidelines, Global Service Data, and coding guidance for knee arthroplasty. Website: https://www.aaos.org

• eviCore by Evernorth. Comprehensive Musculoskeletal Management Guideline CMM-311 (Knee Replacement/Arthroplasty) and CMM-312 (Knee Surgery — Arthroscopic and Open Procedures). Website: https://www.evicore.com

• Cigna. Medical coverage policy update summaries documenting eviCore musculoskeletal guideline revisions effective March 7, 2026. Website: https://static.cigna.com

• Carelon Medical Benefits Management. Joint Surgery Clinical Guideline and Musculoskeletal Program CPT® Codes and Descriptions. Website: https://guidelines.carelonmedicalbenefitsmanagement.com

• TurningPoint Healthcare Solutions. Musculoskeletal Medical Policies and 2026 Updates. Website: https://www.myturningpoint-healthcare.com

• UnitedHealthcare. Computer-Assisted Surgical Navigation for Musculoskeletal Procedures medical policy. Website: https://www.uhcprovider.com

• U.S. National Center for Health Statistics / CMS. ICD-10-CM (FY2026) Official Code Set. Website: https://www.cms.gov/medicare/coding-billing/icd-10-codes

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Reading Recommendations

• CMS TEAM model materials, including episode definitions, quality measures, and participation tracks.

• CY2026 OPPS/ASC Final Rule, particularly the Inpatient Only list phase-out and ASC Covered Procedures List revisions.

• Current eviCore CMM-311 guideline document, verifying the version and effective date in force.

• Payer medical policies on computer-assisted navigation and robotic assistance for orthopedic procedures.

• CJR model evaluation findings and the proposed nationwide expansion.

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Related GoHealthcare Resources (Internal Links)

• GoHealthcare MSK Specialty Procedure Library™ — Knee Arthroscopy and ACL Reconstruction (companion guides).

• GoHealthcare MSK Specialty Procedure Library™ — Shoulder Replacement and Reverse Shoulder Arthroplasty (parallel arthroplasty and site-of-service logic).

• GoHealthcare Revenue Cycle Knowledge Center — APC assignment, payment rates, NCCI/MUE, implant margin, and episode financial modeling.

• GoHealthcare Prior Authorization Playbooks and payer-policy watch. Website: https://www.gohealthcarellc.com

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Recommended Downloads

• Knee Arthroplasty Prior Authorization Checklist (dated and version-stamped).

• Weight-Bearing Radiograph Documentation Template.

• Compartment Logic Reconciliation Worksheet (diagnosis / imaging / procedure).

• Conversion Coding Position Statement Template.

• TEAM Episode Readiness Checklist (KOOS Jr capture, optimization, discharge planning).

• Prospective Site-of-Service Determination Worksheet.

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Visual Recommendations

• Three-compartment knee diagram with code mapping (27447 vs. 27446).

• Decision tree: compartment involvement driving procedure and code selection.

• TEAM episode timeline from anchor event through 30 days post-discharge.

• Site-of-service decision pathway following IPO list elimination.

• Bundling matrix: what is and is not separately reportable with 27447.

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Document History

Version	Date	Summary
1.0	July 2026	Initial publication under GoHealthcare Clinical Procedure Guide Standard v1.0, continuing the Orthopedic Surgery — Knee batch. Two-pass code audit applied at authoring under the standing rule that official long descriptors and primary sources are verified rather than summaries. CPT® descriptors verified against published payer and manufacturer coding references; navigation code status verified directly, confirming that 20986 and 20987 were deleted effective 12/31/2008 while 20985, 0054T, and 0055T remain active; TEAM model parameters verified against CMS model materials; IPO and ASC status verified against the CY2026 OPPS/ASC Final Rule; eviCore CMM-311 revision effective 03/07/2026 verified against published payer policy update summaries. Conversion coding is presented as contested across three published positions rather than settled.

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Educational Disclaimer

Educational Disclaimer

This document is part of the GoHealthcare Practice Solutions Knowledge Center and is intended for educational and operational reference purposes only. It is not a physician training or surgical technique manual and does not replace physician clinical judgment, payer policy review, legal advice, or official CMS guidance. It does not provide procedural technique, implant selection, medication dosing, or physician procedural training. Coverage policies, coding guidance, site-of-service rules, episode-based payment model requirements, and reimbursement requirements change frequently and vary by payer, program, and jurisdiction; always verify current CPT®, HCPCS, and ICD-10-CM codes, current CMS OPPS/ASC addenda, current NCCI edits, current model participation requirements, and the applicable payer's current medical policy at the time of service. The Medicare Inpatient Only list is actively phasing out through January 1, 2029, and the governing commercial knee arthroplasty guideline was revised effective March 7, 2026; both should be re-verified each cycle. Developed by Pinky Maniri, MSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in Healthcare A.I. Governance, Founder and Chief Executive Officer of GoHealthcare Practice Solutions.

Developed by Pinky Maniri

Developed by Pinky Maniri, MSc
CRCR · CSAPM · CSPPM · CSBI · CSPR · CSAF
Certified in Healthcare A.I. Governance
Founder & Chief Executive Officer, GoHealthcare Practice Solutions
A Musculoskeletal Specialty Management Services Organization (MSO)
Prior Authorization · Medical Necessity · Payer Intelligence · Revenue Cycle · Operations