Complicated removal of a total hip prosthesis, including extraction of bone cement (methylmethacrylate), with or without placement of a spacer in the vacated joint space.

Verified May 8, 2026 · 5 sources ↓

Medicare: $1,437.24
Total RVUs: 43.03
Global, days: 90
Region: Hip

Drawn from AAPCZimmerbiometHcmarketplaceCMS

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 5 cited references ↓

Indication documented: infection (with organism if known), mechanical loosening, periprosthetic fracture, or other reason requiring explant
Operative note must identify which components were removed — acetabular cup, femoral stem, femoral head, liner, and any screws or cement mantle
Extent of soft tissue release or bony work described: psoas release, gluteus maximus release, rectus femoris release, trochanteric osteotomy, or use of osteotomes/burr for ingrowth
Spacer type documented if placed — static vs. articulating, antibiotic agent(s) mixed into cement, and how spacer was secured
Intraoperative cultures and pathology specimens documented if taken for infection workup
Cement removal technique noted: manual extraction, flexible osteotomes, ultrasonic tools, or extended trochanteric osteotomy

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 50 Bilateral procedure 51 Multiple procedures 58 Staged or related 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 5 cited references ↓

27091 covers the complicated removal of a total hip prosthesis — both the acetabular and femoral components — along with removal of methylmethacrylate bone cement, and placement of a spacer when indicated. This is the correct code when the operative work goes beyond simple extraction: think extensive soft tissue release due to scarring, trochanteric osteotomy to access the stem, flexible osteotomes or burring to free ingrown components, or thorough debridement in the setting of periprosthetic joint infection (PJI). The simpler, single-component removal without cement work is 27090.

The most common clinical scenario driving 27091 is Stage 1 of a two-stage revision for PJI. The surgeon removes all hardware, debrides infected tissue, and implants an antibiotic-laden cement spacer (static or articulating). The spacer placement is inherent to 27091 — do not separately report +20704. Antibiotic bead placement is also bundled. If an articulating Prostalac-type device is used, some practices additionally report 11981 for the drug delivery implant component, though payer acceptance varies.

27091 carries a 90-day global period. If the second stage reimplantation (typically 27130 or 27134) occurs within that window, bill with modifier 58 to indicate a staged procedure. Modifier 78 applies to any unplanned return to the OR for a complication related to the index procedure during the global. This procedure is classified as a CMS status indicator C (inpatient-only) under OPPS — it is not on the ASC covered procedures list, so the ASC setting is not a covered site of service under Medicare.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	23.74
Practice expense RVU	14.26
Malpractice RVU	5.03
Total RVU	43.03
Medicare national rate	$1,437.24
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$1,437.24
HOPD (APC 5115) Hospital outpatient department	$13,116.76
ASC (PI G2) Ambulatory surgical center (freestanding)	$6,804.43

Common denial reasons

The recurring reasons claims for CPT 27091 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Billed in ASC setting — 27091 is Medicare inpatient-only (status indicator C); ASC claims will deny for incorrect site of service
Modifier 58 missing when Stage 2 reimplantation (27130/27134) is billed inside the 90-day global of the 27091 explant
Separately reported spacer placement code (20704) or antibiotic bead code bundled into 27091 and denied as unbundling
Downcoded to 27090 when documentation does not clearly describe cement removal, bilateral component extraction, or the complexity that distinguishes 27091 from the simple removal code
ICD-10 diagnosis code does not match clinical scenario — using a mechanical loosening code when infection drove the procedure, or missing the laterality qualifier on T84.0xx or M97.0x codes

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 5 cited references ↓

01When does 27090 apply versus 27091?

Use 27090 for uncomplicated removal of a single-component or partial hip prosthesis without cement work. Use 27091 when the procedure involves a total hip prosthesis, removal of methylmethacrylate bone cement, and/or spacer placement. If you removed both the acetabular and femoral components with cement extraction, 27091 is correct regardless of whether a spacer was placed.

02Is the spacer placement separately billable with 27091?

No. Spacer insertion — including antibiotic cement spacers and antibiotic bead placement — is inherent to 27091 and not separately reportable. Do not add +20704. Some practices report 11981 for articulating drug delivery implants like Prostalac; payer acceptance varies and should be verified before billing.

03How do I bill Stage 2 reimplantation during the 90-day global?

27091 carries a 90-day global period. When Stage 2 (typically 27130 or 27134) is performed within that window, append modifier 58 to the reimplantation code. This signals a planned staged procedure and prevents the claim from being denied as a global-period service.

04Can 27091 be performed in an ASC under Medicare?

No. CMS classifies 27091 as an inpatient-only procedure (status indicator C under OPPS). It is not on the ASC covered procedures list. Medicare ASC claims will deny. Commercial payer policies differ — verify contract terms before scheduling in an outpatient or ASC setting.

05What modifier applies if the surgeon needs to return to the OR for a wound complication after 27091?

If the return is for a complication related to the explant (e.g., hematoma evacuation, wound dehiscence), use modifier 78 on the return procedure — unplanned return for a related complication during the global period. If the return is for a completely unrelated condition, use modifier 79.

06Can modifier 22 be used with 27091 for an unusually difficult explant?

Yes. If the procedure required significantly greater work than typical — such as severe cement mantle, multiple prior revisions creating extensive scarring, or extended trochanteric osteotomy for a well-fixed stem — append modifier 22 and attach a cover letter documenting the additional operative time and complexity. Payers require supporting documentation; a generic note will not hold up.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the key complexity drivers from dictation: which components were extracted, whether bone cement was removed and by what technique, the extent of soft tissue or bony release performed, spacer type and antibiotic formulation if applicable, and intraoperative culture data. This prevents downcoding to 27090 and blocks unbundling denials by making clear that spacer insertion is documented as part of the explant procedure rather than a separately billable step.

See how Mira captures CPT 27091 documentation