Medicare Coverage for Hip & Knee Replacement: 2025 Guide
Hip and knee replacement surgeries are among the most common procedures for Medicare beneficiaries. Medicare covers the surgery, hospitalization, skilled nursing facility rehabilitation, home health, and outpatient therapy — but with important rules about how your hospital stay is classified that can make a difference of thousands of dollars.
Joint Replacement Coverage Quick Reference
| Service | Part | Your Cost (2025) | Notes |
|---|---|---|---|
| Hip or knee replacement surgery (inpatient) | Part A | $1,676 deductible per benefit period | Formal inpatient admission required; days 1–60 covered after deductible |
| Hip or knee replacement surgery (outpatient) | Part B | 20% after $257 deductible | Common for knee; less common for hip; no SNF qualification afterward |
| Anesthesia | Part B (outpatient) or A (inpatient) | 20% or covered in inpatient stay | Billed separately by anesthesiologist |
| Pre-op X-rays, MRI, lab work | Part B | 20% after deductible | Standard pre-surgical workup |
| Skilled Nursing Facility (SNF) rehab | Part A | $0 days 1–20; $209.50/day days 21–100 | Requires qualifying 3-day inpatient hospital stay |
| Inpatient Rehabilitation Facility (IRF) | Part A | Same benefit period as hospital | For patients needing intensive rehab (3+ hrs therapy/day) |
| Home health (skilled PT/OT) | Part A/B | $0 for covered services | Requires homebound status and skilled care order |
| Outpatient physical therapy | Part B | 20% after deductible | No hard annual cap; continues with medical necessity |
| Outpatient occupational therapy | Part B | 20% after deductible | For upper extremity function, ADL retraining |
| Walker, cane, crutches | Part B (DME) | 20% after deductible | Standard mobility aids covered as DME |
| Wheelchair (if needed) | Part B (DME) | 20% after deductible | Manual or power; requires physician order |
| Continuous Passive Motion (CPM) machine — knee | Part B (DME) | 20% after deductible | Covered up to 21 days post-op if started within 2 days of surgery |
| Pain medications post-surgery | Part D | Varies by tier | Short-term opioids, NSAIDs, nerve blocks if oral |
Inpatient vs. Outpatient Surgery: Why It Matters for Rehab
Increasingly, joint replacements — particularly knee replacements — are performed as outpatient or short-stay procedures. This is often better for the patient's recovery but creates a Medicare coverage trap for post-surgical rehabilitation.
Inpatient Admission (3+ days)
- Covered under Part A
- Qualifies you for Medicare-covered SNF rehabilitation
- Better option if you need SNF-level post-acute care
- You pay the Part A deductible ($1,676 per benefit period)
Outpatient / Same-Day Surgery
- Covered under Part B at 20% coinsurance
- Does NOT qualify you for SNF coverage — no matter how many nights you spend in the hospital
- Post-surgical care is through home health or outpatient therapy only
- Many patients do well with outpatient surgery + home health; others need SNF intensity
What to discuss with your surgeon before scheduling: If you anticipate needing intensive SNF-level rehabilitation after your joint replacement (especially hip), ask your surgeon whether inpatient admission is medically appropriate. This decision should be made on clinical grounds — not administrative convenience.
The SNF Benefit: Days 1–100
After a qualifying 3-day inpatient hospital stay, Medicare Part A covers skilled nursing facility rehabilitation after joint replacement:
| SNF Days | Your Cost | Medicare Pays |
|---|---|---|
| Days 1–20 | $0 | 100% |
| Days 21–100 | $209.50/day (2025) | All costs above $209.50/day |
| Days 101+ | 100% (not covered) | $0 |
Medigap Plan G covers the $209.50/day SNF coinsurance for days 21–100. With Plan G, your SNF stay is fully covered for the entire 100-day period after the Part A deductible.
Home Health After Joint Replacement
If you go directly home after surgery (inpatient or outpatient), Medicare covers home health services when:
- You are homebound (leaving home requires considerable effort)
- A physician orders skilled care (physical therapy, occupational therapy, skilled nursing)
- You are recovering from surgery and need skilled professional assistance
Home health services covered at 100% (no cost-sharing for covered services) include: physical therapy, occupational therapy, skilled nursing visits, and home health aide services when skilled care is being provided simultaneously.
CPM Machine for Knee Replacement
A Continuous Passive Motion (CPM) machine gently moves the knee through a range of motion while you rest. Medicare Part B covers CPM machine rental when:
- Started within 2 days of knee replacement surgery
- Covered for up to 21 days of rental
- Physician order and documentation of medical necessity required
Not all surgeons prescribe CPMs (evidence is mixed on long-term benefit), but coverage is available when ordered.
Medical Necessity Documentation: Why It Matters
Medicare has a high improper payment rate for joint replacement services due to insufficient medical necessity documentation. To protect your coverage:
- Ensure your surgeon documents conservative treatment history (physical therapy, injections, medications) before surgery authorization
- Conservative treatment failure is typically required for elective joint replacement coverage
- X-ray evidence of significant joint degeneration should be documented
- Functional limitation documentation (difficulty walking, climbing stairs, performing daily activities) strengthens the medical necessity case
Frequently Asked Questions
Yes. Medicare covers knee replacement surgery when it is medically necessary — typically when conservative treatments (PT, injections, pain medication) have failed and X-rays show significant joint damage. The surgery can be covered under Part A (inpatient) or Part B (outpatient), depending on how your admission is classified. You pay the Part A deductible ($1,676) for inpatient surgery, or 20% coinsurance for outpatient surgery after the Part B deductible.
Yes. Medicare covers outpatient physical therapy under Part B at 20% coinsurance after the deductible. There is no hard annual session limit — therapy continues as long as it is medically necessary and you are making progress. Home health PT is covered at no cost when you are homebound and have a physician order. Medigap Plan G covers the 20% PT coinsurance.
Yes, for up to 100 days — but only if you had a qualifying 3-day inpatient hospital stay before going to the SNF. Days 1–20 are covered at 100%. Days 21–100 require a $209.50/day copay (covered by Medigap Plan G). If your hip replacement was done outpatient (same-day), you typically won't qualify for covered SNF care and must pay out of pocket or use home health instead.