Surgical · Knee

Prophylactic fixation of the femur using nailing, pinning, plating, or wiring, with or without methylmethacrylate, to reinforce bone at risk of pathologic fracture before failure occurs.

Verified May 8, 2026 · 6 sources ↓

Medicare: $1,035.76
Total RVUs: 31.01
Global, days: 90
Region: Knee

Drawn from CMSEmednyAAOSAAPCPayerprice

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Imaging findings (plain film, CT, or MRI) documenting the lesion location, size, and degree of cortical involvement establishing impending fracture risk
Specific implant construct documented by name and type (e.g., intramedullary nail, plate and screw system, pinning configuration)
Laterality explicitly stated in the operative note (left vs. right femur)
Use of methylmethacrylate noted if applicable, including volume and placement technique
Underlying diagnosis specified (e.g., metastatic carcinoma to femur, multiple myeloma) with supporting pathology or oncology records when available
Operative note documenting surgical approach, cortical integrity at time of surgery, and reason prophylactic fixation was chosen over observation

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 50 Bilateral procedure 51 Multiple procedures 57 Decision for surgery 58 Staged or related 59 Distinct service 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 27495 covers prophylactic mechanical reinforcement of the femur — nailing, pinning, plating, or wiring — performed to prevent fracture in bone that is structurally compromised but has not yet failed. The indication is typically an impending pathologic fracture from metastatic disease, multiple myeloma, or another lesion that has sufficiently weakened cortical integrity to place the patient at high fracture risk. Methylmethacrylate bone cement may be used adjunctively to fill defects and is included in the code when performed.

This is a high-complexity surgical procedure with a 90-day global period. All routine postoperative management through day 90 is bundled. A decision-for-surgery E/M on the day before or day of the procedure requires modifier 57. Any E/M during the global period for a problem unrelated to the femur reinforcement needs modifier 24. Laterality modifiers LT and RT are expected — claims without them will often be returned or flagged by payers who require anatomic specificity on lower-extremity procedures.

Document the specific implant type and construct, the lesion location and size, imaging findings supporting fracture risk, and any intraoperative methylmethacrylate use. Payers covering this procedure under oncologic indications often require prior authorization and may request the radiologic evidence (plain film, CT, or MRI) that established impending fracture risk. Coding the underlying pathology correctly in ICD-10 — distinguishing primary bone lesion from metastatic disease — directly affects medical necessity review.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	16.13
Practice expense RVU	11.45
Malpractice RVU	3.43
Total RVU	31.01
Medicare national rate	$1,035.76
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	$1,035.76
HOPD (APC 5114) Hospital outpatient department	$7,413.38
ASC (PI J8) Ambulatory surgical center (freestanding)	$4,971.95

Common denial reasons

The recurring reasons claims for CPT 27495 get rejected.

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

Missing laterality modifier — payers requiring LT or RT will return or deny the claim without anatomic specificity
Medical necessity not established — no imaging or clinical documentation demonstrating impending fracture risk prior to surgery
Incorrect ICD-10 linkage — mismatched or nonspecific diagnosis codes (e.g., unspecified bone lesion) fail medical necessity screens
Prior authorization not obtained — oncologic prophylactic procedures are frequently prior-auth required by commercial payers
Global period conflict — postoperative E/M billed without modifier 24 when visit was for an unrelated condition

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01What ICD-10 codes typically support medical necessity for 27495?

Metastatic malignancy to the femur (C79.51), multiple myeloma with bone involvement, and primary bone neoplasms with cortical destruction are the most accepted diagnoses. Use the most specific code available — unspecified bone lesion codes are a common medical necessity denial trigger.

02Is methylmethacrylate separately billable when used with 27495?

No. Methylmethacrylate use is included in the 27495 descriptor when performed as part of the prophylactic femur fixation. Do not bill it separately.

03Can 27495 be billed bilaterally?

Yes, but bilateral prophylactic femur fixation in one session is uncommon and will draw scrutiny. If performed, append modifier 50 and document independent clinical justification for each side. Some payers require two line items with LT and RT instead of a single line with modifier 50 — verify payer preference before submitting.

04What modifier applies if the patient returns to the OR within the 90-day global for a related complication?

Modifier 78 — unplanned return to the OR for a procedure related to the original surgery. Do not use modifier 79 for a related return; 79 is strictly for unrelated procedures performed by the same surgeon during the postoperative period.

05Is a same-day decision-for-surgery E/M separately billable?

Yes, with modifier 57 appended to the E/M code. Modifier 57 is required when the decision for a major procedure (90-day global) is made at the E/M visit on the day of or day before surgery. Without modifier 57, the E/M bundles into the global.

06How does 27495 differ from fracture repair codes like 27506 or 27507?

27495 is prophylactic — the bone has not fractured. Fracture repair codes apply after failure has occurred. Coding 27495 for a completed pathologic fracture, or a fracture code for an impending fracture, is a misrepresentation and a common audit target in oncology cases.

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 implant type and construct, lesion location and cortical involvement from intraoperative findings, methylmethacrylate use, and explicit laterality from dictation — the four elements most commonly missing when 27495 claims are audited or returned. Incomplete implant documentation is the leading audit flag on prophylactic femur fixation; having it in the structured note at time of dictation eliminates the retrospective chase.

See how Mira captures CPT 27495 documentation