Procedure coding
Procedure coding for joint replacement surgery (arthroplasty) is well-established in many European countries. The procedure codes differentiate between the anatomical site of the intervention, such as the hip joint or knee joint, and the type of procedure performed, whether it’s a partial or total replacement, or a primary or revision procedure. Additionally, the codes can specify the type of prosthesis used.
The adoption of innovative technologies in joint replacement surgery necessitates the creation of new codes in procedural nomenclatures. For example, in England, the new OPCS sub-chapter O51 “Prosthetic replacement of wrist joint” was implemented in 2023, with nine new codes for primary and revision wrist joint replacement procedures.
Payment mechanism
The payment model for joint replacement varies by country and the type of procedure.
In some European countries, joint replacement surgery is reimbursed solely via the diagnosis-related group (DRG) mechanism. The DRGs might be different depending on the type of procedure (primary or revision surgery, partial or total replacement). For example, in Italy, there are separate DRGs for partial (DRG 471 ”Bilateral or multiple major interventions on the joints of the lower limbs” with a national tariff of €13,244) and total (DRG 545 “Revision of hip or knee replacement” with a national tariff of €11,152) bilateral revision knee arthroplasty.
In some countries (e.g., France and Germany), joint replacement materials attract additional reimbursement, paid on top of the DRG tariff. Add-on reimbursement can be either generic (at the class level, as in Germany) or brand-specific (with specific LPPR codes for individual brands of joint prostheses in France). For example, in 2024, six devices for joint replacement were assessed by the National Committee for the evaluation of medical devices and health technologies (CNEDiMTS) at the French National Authority for Health (HAS), and four devices were registered in the LPPR.
Policy considerations
Joint replacement procedures are well-established technologies; they are unlikely to be subject to specific policies from payers or national decision-makers in the countries where such frameworks exist.
National policies can be implemented to support the specific conditions for procedure provision, thereby improving patient access and reducing healthcare costs. For example, in 2022, NHS England and NHS Improvement announced the rolling out of the same-day hip replacement, which was primarily performed in Merseyside. Liverpool University Hospital is now expanding this day case procedure to more patients to reduce waiting lists for orthopedic treatments and enable patients to recover at home.
Health technology assessment
Arthroplasty rarely becomes a subject for HTAs. The exception is novel joint replacement procedures involving innovative and expensive medical devices. For example, in May 2022, the National Institute for Health and Care Excellence (NICE) published interventional procedure guidance on supercapsular percutaneously assisted total hip arthroplasty for osteoarthritis, concluding that evidence on safety and efficacy is limited in quality and quantity. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research.
Future challenges
Many joint replacement interventions have established reimbursement and funding in most European countries. Rapid development of novel technologies, using innovative and expensive devices and materials (e.g., robotics, AI-assisted surgery, custom and 3D‑printed implants), would be a subject of health technology assessments.
Another challenge is the further adoption of arthroplasty procedures to support their provision in day case settings, which would improve patient access to the procedure and reduce the financial burden on healthcare.
How can MTRC help?
Development of reimbursement analysis (procedure coding, payment mechanism, reimbursement tariffs, and policy considerations)
Development of market access strategy
Development of the value dossier
Performing evidence gap analysis for novel technologies
Development of reimbursement and HTA submission dossiers
Adaptation of the global health economic model to EU settings
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