Description
Documentation will be reviewed to determine if total hip arthroplasty meets Medicare coverage requirements.
Affected Code(s)
CPT Codes- 27130, 27132, 27134, 27137, 27138 (FCSO, NGS, Novitas, Palmetto, Noridian)
PCS Codes (FCSO ONLY) - 0SP90JZ, 0SPB0JZ, 0SR9019, 0SR901A, 0SR901Z, 0SR9029, 0SR902A, 0SR902Z, 0SR9039, 0SR903A, 0SR903Z, 0SR9049, 0SR904A, 0SR904Z, 0SR9069, 0SR906A, 0SR906Z, 0SR907Z, 0SR90EZ, 0SR90J9, 0SR90JA, 0SR90JZ, 0SR90KZ, 0SRB019, 0SRB01A,0SRB01Z, 0SRB029, 0SRB02A, 0SRB02Z, 0SRB039, 0SRB03A, 0SRB03Z, 0SRB049, 0SRB04A, 0SRB04Z, 0SRB069, 0SRB06A, 0SRB06Z, 0SRB07Z, 0SRB0EZ, 0SRB0J9, 0SRB0JA, 0SRB0JZ, 0SRB0KZ, 0SW90JZ, 0SWB0JZ
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. First Coast Service Options, Inc., LCD L33618- Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 01/8/2019
9. First Coast Service Options, Inc., LCA A57765- Billing and Coding: Major Joint Replacement (Hip and Knee); Effective 10/03/2018; Revised 10/01/2023
10. Novitas Solutions, Inc., LCD L36007- Lower Extremity Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 11/14/2019
11. Novitas Solutions, Inc., LCA A56796- Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee); Effective 8/8/2019; Revised 5/02/2022
12. National Government Services, Inc., LCD L36039-Total Joint Arthroplasty; Effective 12/01/2015; Revised 10/10/2019
13. National Government Services, Inc., LCA A57428- Billing and Coding: Total Joint Arthroplasty; Effective 10/10/2019; Revised 11/30/2023
14. Palmetto GBA, LCD L33456-Total Joint Arthroplasty; Effective 10/01/2015; Revised 6/15/2023
15. Palmetto GBA, LCA A56777- Billing and Coding: Total Joint Arthroplasty; Effective 8/01/2019; Revised 4/01/2024
16. Noridian Healthcare Solutions, LLC, LCD L34163- Total Hip Arthroplasty; Effective 10/01/2015; Revised 12/01/2019
17. Noridian Healthcare Solutions, LLC, LCD L36573- Total Hip Arthroplasty; Effective 9/7/2016; Revised 12/01/2019
18. Noridian Healthcare Solutions, LLC, LCA A57683- Billing and Coding: Total Hip Arthroplasty; Effective 12/01/2019
19. Noridian Healthcare Solutions, LLC, LCA A57684- Billing and Coding: Total Hip Arthroplasty; Effective 12/01/2019
20. AMA CPT Codebook
21. ICD-10-PCS Procedure Codebook