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Understanding Medicare Coverage for Hip Surgery

Hip surgery addresses problems ranging from osteoarthritis to fractures to hip replacement needs. Medicare, the federal health insurance program for people 65 and older, covers many types of hip surgical procedures when medically necessary. This guide provides information about how Medicare coverage works for hip surgery, what procedures may be covered, and what costs you might encounter.

Medicare has two main parts that relate to surgery: Part A covers hospital stays, and Part B covers doctor services and outpatient procedures. When you need hip surgery, the location where the procedure happens determines which part of Medicare pays. If your surgery occurs in a hospital as an inpatient procedure, Part A typically covers hospital costs including the operating room, anesthesia, and hospital stay. If the surgery happens in an outpatient surgical center or doctor's office, Part B generally covers the surgeon's fees and facility costs.

According to the Centers for Medicare and Medicaid Services (CMS), hip replacement surgery represented over 370,000 procedures annually among Medicare beneficiaries in recent years. This high volume means Medicare has clear established procedures for covering these surgeries. The key to understanding your potential coverage is knowing that Medicare determines coverage based on medical necessity—meaning a doctor must document that the surgery is needed to treat your condition, not for cosmetic or elective reasons.

It's important to understand that having Medicare does not automatically mean all hip surgery costs are covered without your contribution. Medicare beneficiaries typically pay deductibles, copayments, or coinsurance amounts depending on which part of Medicare is involved and whether you have supplemental coverage. The specific amounts you owe depend on your particular Medicare plan and your annual deductible status.

Practical Takeaway: Before pursuing hip surgery, obtain written documentation from your doctor explaining the medical reasons for the procedure. This documentation supports the medical necessity determination that Medicare uses when reviewing coverage decisions. Keep this information organized for reference when discussing your surgery with Medicare or your healthcare providers.

Types of Hip Surgery That Medicare May Cover

Medicare covers various hip surgical procedures when they meet medical necessity requirements. Hip replacement surgery, also called total hip arthroplasty, is one of the most common covered procedures. This surgery replaces the damaged hip joint with an artificial joint. Hip resurfacing is another option where only the surface of the hip joint is replaced with metal components, typically performed on younger patients with specific conditions. Partial hip replacement, or hemiarthroplasty, replaces only part of the hip joint and is often used for certain types of hip fractures.

Hip arthroscopy is a minimally invasive procedure where a surgeon uses a small camera to see inside the joint and repair problems like labral tears or impingement. Medicare covers arthroscopy when the condition cannot be effectively treated with conservative measures. Femoral osteotomy and pelvic osteotomy are surgical procedures that reposition hip bone to improve joint alignment and are covered when appropriate for specific conditions. Open reduction and internal fixation (ORIF) is performed for hip fractures to stabilize the bone with hardware, and Medicare covers this for acute fractures.

Hip arthrocentesis, a procedure where fluid is removed from the hip joint, may be covered for diagnostic or therapeutic purposes. Removal of hardware—taking out pins, plates, or screws from previous hip surgery—is typically covered. Revision hip surgery, performed when a previous hip replacement fails or wears out, is also generally covered by Medicare. According to data from the National Institutes of Health, hip replacement provides significant pain relief and improved mobility for 85 to 90 percent of patients, which supports Medicare's coverage decisions for this procedure.

The specific procedure code and diagnosis code your doctor uses significantly impacts whether Medicare covers the surgery. Procedures performed for degenerative joint disease, rheumatoid arthritis, hip fracture, avascular necrosis, and certain other conditions have established coverage policies. Procedures performed solely for cosmetic reasons, to address athletic performance, or for conditions that can be managed without surgery typically do not receive coverage.

Practical Takeaway: Ask your orthopedic surgeon to explain specifically which hip procedure they recommend and why it is necessary for your particular condition. Request the procedure name and code so you can reference it when contacting Medicare. Understanding the specific type of surgery helps you know what questions to ask and what information to gather about your coverage.

Medicare Part A Hospital Coverage for Hip Surgery

When hip surgery is performed as an inpatient procedure in a hospital, Medicare Part A covers most of the hospital-related costs. Part A is hospital insurance, and it pays for semiprivate rooms, meals, nursing care, anesthesia, operating room use, and medical supplies during your hospital stay. If you have already met your annual Part A deductible, you do not pay the deductible again that year. For 2024, the Part A deductible is $1,632 for each benefit period (a benefit period begins when you enter the hospital and ends after you have been out of the hospital for 60 consecutive days).

After you pay the deductible, Medicare Part A covers all approved hospital costs for the first 60 days of your hospital stay. If your stay extends beyond 60 days, you pay a daily coinsurance amount ($408 per day in 2024 for days 61-90). If you need more than 90 days in the hospital, you can use your 60 "lifetime reserve days," paying a higher coinsurance amount ($816 per day in 2024) for those days. After your lifetime reserve days are exhausted, you pay all remaining hospital costs.

Most hip replacement surgeries result in hospital stays of one to three days, so most patients' costs are limited to the Part A deductible if they haven't already met it that year. However, patients with complications might stay longer. Part A also covers the costs associated with hospital discharge planning and, in many cases, post-acute care in a skilled nursing facility if medically necessary. If your doctor determines you need skilled nursing care after surgery (such as physical therapy and nursing services that require skilled care), Medicare Part A may cover up to 100 days of skilled nursing facility care, though you pay coinsurance for days 21-100.

Part A does not cover all hospital stays equally. Your hospital stay must be deemed medically necessary and ordered by a physician. If the hospital or Medicare determines your stay could be handled in an outpatient setting, Part A may not cover it. Additionally, Part A does not cover private rooms unless medically necessary, television, telephone, or personal items. Understanding what Part A covers helps you budget for hip surgery and avoid unexpected bills.

Practical Takeaway: Before your scheduled hip surgery, contact Medicare or your hospital's billing department to find out whether you have already met your annual Part A deductible. Knowing this helps you understand your maximum out-of-pocket costs. Ask the hospital to provide an estimate of costs you will owe based on your specific situation.

Medicare Part B Coverage for Surgeon and Doctor Services

Medicare Part B covers the physician services related to your hip surgery, whether the surgery happens in a hospital operating room or an outpatient surgical center. Part B pays for your orthopedic surgeon's fees, anesthesiologist services, and other physicians who provide care during your surgery and recovery. Part B operates differently from Part A—instead of hospital deductibles and coinsurance for length of stay, Part B requires you to meet an annual deductible and then pay 20 percent coinsurance for most services after the deductible is met.

For 2024, the Part B annual deductible is $240. After you meet this deductible, you typically pay 20 percent of the Medicare-approved amount for physician services. This means if your orthopedic surgeon's Medicare-approved fee for your hip replacement surgery is $3,000, you would pay $600 (20 percent) after meeting your deductible, and Medicare would pay $2,400. The surgeon cannot bill you for more than the Medicare-approved amount if they accept Medicare assignment, which most do.

Part B also covers pre-operative consultations and testing your surgeon orders before surgery, such as blood work, imaging studies, and electrocardiograms (EKGs). Post-operative follow-up visits with your surgeon are covered for up to 90 days after your surgery under the surgical global period. This means any visits related to your surgery recovery during this time are included as part of the surgeon's fee, and you only pay your 20 percent coinsurance once per the global package, not for each visit. If complications arise requiring additional surgery, those may be covered as separate