Medical Specialty Solutions - Musculoskeletal Surgery (Hip, Knee, and Shoulder) Utilization Review Matrix 2024 Form

• Effective 1/20/2023, National Imaging Associates, Inc. is now a subsidiary of Evolent Health. Evolent Health and its affiliates and subsidiaries collectively referred to as “Evolent.”

  1 – Fidelis Care – Hip, Knee, and Shoulder Utilization Code Matrix 2024 (Revised 2.2.2024)

  Fidelis Care Utilization Review Matrix 2024 Musculoskeletal Surgery (Hip, Knee, and Shoulder)

  HIP SURGERY PROCEDURES Procedure Name Primary CPT Code Allowable Billed Groupings Additional Covered Procedures/Codes Authorization is provided at the procedure level. There are multiple CPT codes that can be associated with each procedure. These are assumed to be part of the primary request and, when completed in combination, do not require a separate authorization. Revision/Conversion Hip Arthroplasty 27134 27132, 27134, 27137, 27138

  Total Hip Arthroplasty/Resurfacing 27130 27130, S2118

  Femoroacetabular Impingement (FAI) Hip Surgery 29914 29914, 29915, 29916 Loose Body Removal: 29861

  Chondroplasty: 29862

  Synovectomy: 29863
  Hip Surgery – Other 29863 29860, 29861, 29862, 29863

2 – Fidelis Care – Hip, Knee, and Shoulder Utilization Code Matrix 2024 (Revised 2.2.2024

KNEE SURGERY PROCEDURES Procedure Name Primary CPT Code Allowable Billed Groupings Additional Covered Procedures/Codes Authorization is provided at the procedure level. There are multiple CPT codes that can be associated with each procedure. These are assumed to be part of the primary request and, when completed in combination, do not require a separate authorization. Revision Knee Arthroplasty 27487 27486, 27487

Total Knee Arthroplasty (TKA) 27447 27447

Partial-Unicompartmental Knee Arthroplasty (UKA) 27446 27446, 27438

Knee Manipulation under Anesthesia (MUA) 27570 27570, 29884

3 – Fidelis Care – Hip, Knee, and Shoulder Utilization Code Matrix 2024 (Revised 2.2.2024

KNEE SURGERY PROCEDURES Procedure Name Primary CPT Code Allowable Billed Groupings Additional Covered Procedures/Codes Knee Ligament Reconstruction/Repair 29888 27405, 27407, 27409, 27427, 27428, 27429, 29888, 29889 Meniscectomy: 27332, 27333, 27403, 29868, 29880, 29881, 29882, 29883

Autologous chondrocyte implantation: 27412

Osteochondral Allograft/Autograft: 27415, 27416, 29866, 29867

Anterior tibial tubercleplasty: 27418

Reconstruction of Dislocating Patella: 27420, 27422, 27424

Lateral Release: 27425, 29873

Loose Body Removal: 29874

Synovectomy: 29875, 29876

Chondroplasty: 29877

Microfracture: 29879

OCD Lesion: 29885, 29886, 29887

4 – Fidelis Care – Hip, Knee, and Shoulder Utilization Code Matrix 2024 (Revised 2.2.2024

KNEE SURGERY PROCEDURES Procedure Name Primary CPT Code Allowable Billed Groupings Additional Covered Procedures/Codes Knee Meniscectomy/Meniscal Repair/Meniscal Transplant 29880 27332, 27333, 27403, 29868, 29880, 29881, 29882, 29883 Autologous chondrocyte implantation: 27412

Osteochondral Allograft/Autograft: 27415, 27416, 29866, 29867

Anterior tibial tubercleplasty: 27418

Reconstruction of Dislocating Patella: 27420, 27422, 27424

Lateral Release: 27425, 29873

Loose Body Removal: 29874

Synovectomy: 29875, 29876

Chondroplasty: 29877

Microfracture: 29879

Misc. (see code description): G0289

OCD Lesion: 29885, 29886, 29887 Knee Surgery – Other 29879 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 29866, 29867, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29885, 29886, 29887, G0289

5 – Fidelis Care – Hip, Knee, and Shoulder Utilization Code Matrix 2024 (Revised 2.2.2024

SHOULDER SURGERY PROCEDURES Procedure Name Primary CPT Code Allowable Billed Groupings Additional Covered Procedures/Codes Authorization is provided at the procedure level. There are multiple CPT codes that can be associated with each procedure. These are assumed to be part of the primary request and, when completed in combination, do not require a separate authorization. Revision Shoulder Arthroplasty 23474 23473, 23474

Total/Reverse Shoulder Arthroplasty or Resurfacing 23472 23472

Partial Shoulder Arthroplasty/Hemiarthroplasty 23470 23470

Frozen Shoulder Repair/Adhesive Capsulitis 29825 29825 Manipulation under Anesthesia: 23700 Shoulder Labral Repair

29806 23450, 23455, 23460, 23462, 23465, 23466, 29806, 29807 Claviculectomy: 23120, 23125

Acromioplasty: 23130

Coracoacromial ligament release: 23415

Biceps Tenotomy/Tenodesis: 23405, 23430, 29828

Synovectomy: 29820, 29821

Debridement: 29822, 29823

Distal Clavicle Excision (Mumford procedure): 29824

Subacromial Decompression: +29826

6 – Fidelis Care – Hip, Knee, and Shoulder Utilization Code Matrix 2024 (Revised 2.2.2024

SHOULDER SURGERY PROCEDURES Procedure Name Primary CPT Code Allowable Billed Groupings Additional Covered Procedures/Codes Shoulder Rotator Cuff Repair 29827 23410, 23412, 23420, 29827 Claviculectomy: 23120, 23125

Acromioplasty: 23130

Coracoacromial ligament release: 23415

Biceps Tenotomy/Tenodesis: 23405, 23430, 29828

Synovectomy: 29820, 29821

Debridement: 29822, 29823

Distal Clavicle Excision (Mumford procedure): 29824

Subacromial Decompression: +29826 Shoulder Surgery - Other 23415 23120, 23125, 23130, 23405, 23415, 23430, 23700, 29805, 29819, 29820, 29821, 29822, 29823, 29824, 29825, +29826, 29828

 Musculoskeletal surgery services rendered through the Emergency Department are not managed by NIA*

 NIA does not prior authorize or manage the facility precertification for musculoskeletal surgery services

 NOTE: If any joint surgery is to be performed bilaterally on the same date of service, separate authorizations are required