Description
For purposes of coverage under Medicare, Total Knee Arthroplasty (TKA), also referred to as a joint replacement, has proven to be an important medical advancement. Knee Arthroplasty is most commonly performed for diseases which affect the function of the knee joint (the lower end of the femur, the upper end of the tibia and patella). Occasionally, there may be a need to redo a TKA, often referred to as a revision total knee. In revisional surgery it is important to provide replacement of the components of the previous surgery responsible for the failure. The goal of total knee replacement surgery is to relieve pain and improve or increase functional activity of the beneficiary. This review only focuses on total (involving the entire joint) knee arthroplasties. The documentation will be reviewed to determine if a TKA is medically necessary according to the guidelines outlined in the LCDs and LCAs of FCSO, Novitas, NGS, Palmetto GBA, and Noridian.
Affected Code(s)
CPT 27445, 27447, 27486, 27487
PCS Codes (FCSO ONLY) - 0SPC0JZ, 0SPD0JZ, 0SRC069, 0SRC06A, 0SRC06Z, 0SRC07Z, 0SRC0EZ, 0SRC0J9, 0SRC0JA, 0SRC0JZ, 0SRC0M9, 0SRC0MA, 0SRC0MZ, 0SRC0N9, 0SRC0NA, 0SRC0NZ, 0SRD0EZ, 0SRD0M9, 0SRD0MA, 0SRD0MZ, 0SRD0N9, 0SRD0NA, 0SRD0NZ, 0SRC0KZ, 0SRD069, 0SRD06A, 0SRD06Z, 0SRD07Z, 0SRD0J9, 0SRD0JA, 0SRD0JZ, 0SRD0KZ, 0SRT07Z, 0SRT0J9, 0SRT0JA, 0SRT0JZ, 0SRT0KZ, 0SRU07Z, 0SRU0J9, 0SRU0JA, 0SRU0JZ, 0SRU0KZ, 0SRV07Z, 0SRV0J9, 0SRV0JA, 0SRV0JZ, 0SRV0KZ, 0SRW07Z, 0SRW0J9, 0SRW0JA, 0SRW0JZ, 0SRW0KZ, 0SWC0JZ, 0SWD0JZ
Applicable Policy References
1. 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. 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. 42 CFR §482.24 - Condition of participation: Medical record services
8. Medicare Benefit Policy Manual, Chapter 16- General Exclusion from Coverage, §10- General Exclusions from Coverage, §20- Services Not Reasonable and Necessary
9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §40- Surgeons and Global Surgery
10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
11. Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services, §6.5.2-Conducting Patient Status Reviews of Claims for Medicare Part A Payment for Inpatient Hospital Admissions
12. Medicare Program Integrity Manual, Chapter 13- Local Coverage Determinations, §13.5.4-Reasonable and Necessary Provision LCDs.
13. First Coast LCD L33618- Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 01/08/2019
14. First Coast LCA A57765- Billing and Coding: Major Joint Replacement (Hip and Knee); Effective 10/03/2018; Revised 01/01/21.
15. First Coast LCA A55899- Major joint replacement (hip and knee) revision to the Part A and Part B LCD; Effective 02/15/2018; Retired 07/30/21
16. First Coast LCA A57986- Major joint replacement (hip and knee) revision to the Part A and Part B Billing and Coding Article; Effective 02/18/2020; Retired 07/30/21
17. First Coast LCA A56153- Major joint replacement (hip and knee) revision to the Part A and Part B LCD; Effective 10/01/2018; Retired 07/30/2021
18. Novitas LCD L36007- Lower Extremity Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 11/14/2019
19. Novitas LCA A56796- Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee); Effective 08/08/2019; Revised 05/02/2022
20. NGS LCD L36039-Total Joint Arthroplasty; Effective 12/01/2015; Revised 10/10/2019
21. NGS LCA A57428- Billing and Coding: Total Joint Arthroplasty; Effective 10/10/2019
22. Palmetto LCD L33456-Total Joint Arthroplasty; Effective 10/01/2015; Revised 07/15/21
23. Palmetto LCA A56777- Billing and Coding: Total Joint Arthroplasty; Effective 08/01/2019; Revised 10/17/2019
24. Noridian LCD L36575- Total Knee Arthroplasty; Effective 09/07/2016; Revised 12/01/2019
25. Noridian LCA A57685- Billing and Coding: Total Knee Arthroplasty; Effective 12/01/2019
26. Noridian LCD L36577- Total Knee Arthroplasty; Effective 09/07/2016; Revised 12/01/2019
27. Noridian LCA A57686- Billing and Coding: Total Knee Arthroplasty; Effective 12/01/2019
28. Annual American Medical Association CPT Manual
29. ICD-10-PCS Manual