Prophylactic mechanical reinforcement of the tibia using nailing, pinning, plating, or wiring — with or without methylmethacrylate — to prevent pathologic or stress fracture before it occurs.

Verified May 8, 2026 · 6 sources ↓

Medicare: $678.71
Work RVU: 10.23
Global, days: 90
Region: Foot & ankle

Drawn from CMSNIHOssioEmednyAAPC

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Explicit indication for prophylactic (not therapeutic) fixation — document the lesion, risk factor, or clinical rationale in the operative note
Name the fixation construct used: intramedullary nail, pin, plate, or wire — 'standard fixation' is insufficient
Document use or non-use of methylmethacrylate; if used, note volume and technique
Pre-operative imaging or bone survey confirming the impending fracture risk (lesion size, cortical involvement, or bone density data)
If performed concurrently with another major procedure (e.g., total ankle replacement), document that the tibial fixation was a distinct, separately planned intervention
Surgeon attestation that the bone has not yet fractured at the time of fixation — distinguishes 27745 from fracture-treatment codes

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 25 Significant separate E/M 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 58 Staged or related 59 Distinct service 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 27745 covers prophylactic stabilization of the tibia in patients at elevated fracture risk — metastatic lesions, impending pathologic fracture, severe osteopenia, or as an adjunct during procedures like total ankle replacement where the medial malleolus is vulnerable. The surgeon places an intramedullary nail, pin, plate, or wires; methylmethacrylate augmentation is included when used and does not warrant a separate line item.

This code sits in a 90-day global period, so all routine follow-up through postoperative day 90 is bundled. When 27745 is performed as a staged or concurrent procedure alongside another major surgery — for example, prophylactic tibial nailing at the time of total ankle arthroplasty — modifier selection at time of billing determines whether payment is processed correctly. The procedure itself is distinct from fracture treatment codes (e.g., 27756–27759), which address fractures already present.

Documentation must clearly establish why prophylactic fixation was indicated rather than reactive fracture repair. Operative notes should name the specific fixation construct used, describe the lesion or risk factor driving the decision, and confirm whether methylmethacrylate was employed. Payers may request supporting imaging and oncology or bone density records to justify the prophylactic, rather than therapeutic, intent.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (10.23) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (20.32) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	10.23
Practice expense RVU	8.18
Malpractice RVU	1.91
Total RVU	20.32
Medicare national rate	$678.71
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	$678.71
HOPD (APC 5114) Hospital outpatient department	$7,413.38
ASC (PI J8) Ambulatory surgical center (freestanding)	$4,847.17

Common denial reasons

The recurring reasons claims for CPT 27745 get rejected.

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

Payer downcodes to a fracture-treatment code (27756–27759) when the operative note fails to clearly state prophylactic intent before fracture
Bundling denial when billed same-session with a primary lower-leg or ankle procedure without modifier 59 or 51 to establish distinct service
Lack of medical necessity documentation — payer requests imaging or oncology records to support impending fracture risk and denies without them
Global period conflict — follow-up visits billed without modifier 24 or 25 during the 90-day post-op window are denied as included services
Incorrect site-of-service billing — ASC and HOPD payment rates differ substantially; mismatched facility type on the claim triggers adjustment or denial

Frequently asked questions

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

01What distinguishes 27745 from fracture-treatment codes like 27756 or 27759?

27745 is used when the tibia is intact but at high risk — metastatic lesion, severe osteopenia, or structural vulnerability during another procedure. Fracture-treatment codes apply when a fracture already exists. If the operative note describes treating a fracture, payers will reject 27745 regardless of the surgeon's intent.

02Can 27745 be billed at the same session as a total ankle replacement?

Yes. Prophylactic tibial nailing performed alongside total ankle arthroplasty is a separately reportable service. Use modifier 59 (or XS if required by payer) to establish it as a distinct procedural service. Document that the fixation was planned independently to protect the medial malleolus, not simply part of the ankle approach.

03Is methylmethacrylate billed separately when used with 27745?

No. The code descriptor explicitly includes methylmethacrylate with or without. Billing a separate implant or material code for the cement alongside 27745 will be bundled and denied.

04What modifier applies if a significantly more complex fixation was required than typical?

Modifier 22 is appropriate when operative complexity substantially exceeded the norm — for example, extensive cortical destruction from a large lytic lesion requiring a longer construct or additional fixation points. Attach a cover letter quantifying the added operative time and work; payers routinely request it before approving the upcharge.

05How does the 90-day global period affect billing for oncology follow-up visits?

Routine post-op tibia checks are bundled through day 90. If the patient returns for management of their underlying malignancy — not the surgery — bill the E/M with modifier 24 and an unrelated ICD-10 diagnosis. Without modifier 24, the claim will deny as included in the global package.

06Is 27745 performed bilaterally in practice, and how should bilateral cases be billed?

Bilateral tibial prophylactic fixation is uncommon but not impossible in patients with bilateral metastatic disease. If performed at the same session, append modifier 50 and bill on a single line. Confirm the payer accepts modifier 50 rather than separate LT/RT lines — some commercial payers require the latter.

Sources & references

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

Mira Scribe

Mira's AI scribe captures the prophylactic indication (lesion type, impending fracture risk, or concurrent procedure context), the fixation construct by name (nail, pin, plate, or wire), methylmethacrylate use, and the surgeon's explicit statement that no fracture was present at time of fixation. That last detail is what separates a clean 27745 claim from an automatic downcode to a fracture-treatment code on audit.

See how Mira captures CPT 27745 documentation