This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Total Joint Arthroplasty.
Coding Information:
Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.
The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.
Documentation Requirements
In order to qualify for coverage of both Medicare Part A inpatient services and Part B provider services the medical record must contain documentation that fully supports the medical necessity and justification of the procedure performed and must be made available to National Government Services upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act.
A history and physical, discharge summary, physician progress notes and an operative report are typically in the hospital record for the procedures in the related LCD. Other relevant information addressing coverage criteria related to the patient’s episode of care prior to the hospitalization, should be included in the hospital record (see below). Failure to include this information in the hospital record may result in denial of coverage for Part A services and trigger a review of the Part B provider claim to determine whether the Part B service rendered was reasonable and necessary.
When the procedure is indicated for advanced joint disease, the following should be documented in the medical record:
- Arthritis of the knee or hip supported by X-ray or MRI. The X-ray or MRI should demonstrate one of the following:
- subchondral cysts,
- subchondral sclerosis,
- periarticular osteophytes,
- joint subluxation,
- joint space narrowing,
- avascular necrosis, or
- bone on bone articulations
- The extent to which pain or functional disability interferes with ADLs (functional disability), increases with activity or increases with weight bearing. ADLs include, but are not limited to, dressing, feeding, toileting, grooming, physical ambulation (including balance/risk of falls), and bathing.
- Documentation of unsuccessful non-surgical medical management. Documentation should establish a history of a reasonable attempt at conservative therapy as appropriate for the patient in their current episode of care. Clinically appropriate non-surgical medical management typically includes one or more of the following:
- anti-inflammatory medications and/or analgesics; and/or
- flexibility and muscle strengthening exercises; and/or
- supervised physical therapy; and/or
- assistive device use; and/or
- reasonable activity restrictions; and/or
- weight reduction as appropriate; and/or
- therapeutic injections into the joint as appropriate.
Non-surgical medical management may be inappropriate, ineffective or counterproductive when one or more of the following is present:
- bone on bone articulation; and/or
- severe deformity; and/or
- Severe pain (particularly at rest) and significant disabling interference with activities of daily living (ADL).
- For patients with significant conditions or co-morbidities, such as coronary artery disease or obstructive pulmonary disease, the risk/benefit of the TKA or THA should be appropriately addressed in the medical record.
Medical record documentation for other TKA and THA indications outlined in the LCD should include the following, when indicated:
- Supporting evidence (e.g., pathology reports and referral from an Oncologist for a malignancy of the joint or X-ray of a fracture).
- The extent to which pain or functional disability interferes with ADLs (functional disability), increases with initiation of activities or weight bearing.
- For patients with significant conditions or co-morbidities, such as coronary artery disease or obstructive pulmonary disease, the risk/benefit of the TKA or THA should be appropriately addressed in the medical record.
- When infection is the reason for revision TKA or THA surgery, laboratory and/or pathology reports must be in the medical record and all documentation regarding treatment of the infection and a physician note indicating that it is appropriate to proceed with surgery should be in the medical record as well.
In order to meet Medicare’s reasonable and necessary (R&N) threshold for coverage of a procedure, the documentation should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need, is at least as beneficial as existing alternatives, and is furnished within accepted standards of medical practice in a setting appropriate for the patient’s medical needs and condition). Lacking compelling arguments for an exception in the supporting documentation, the hospital (FISS claim) and physician services (MCS claim) may be denied.
If the required criteria outlined in the Indications section above are not met, but the treating physician feels that performing the procedure is within the current standards of care, then the documentation must include, in addition to the above, other information which confirms that the services performed clearly were appropriate. This may include, for example, evidenced based clinical practice guidelines or published and peer reviewed literature in support. For example, if certain conservative measures are not necessary or appropriate for a given patient, it should be directly noted in the pre-procedure documentation. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre-procedure record and if consistent with the episode of care for the patient as documented in patient records and claim history.
In addition to the medical necessity of the procedure itself, the medical necessity of the site of service should also be evident from review of the medical record.
Utilization Guidelines
It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters they may be subject to review for medical necessity.
The devices/implants utilized for total knee and total hip replacement surgeries are regulated by the FDA as medical devices. The devices used should be class II or class III devices that meet the requirements outlined in CFR 21, Chapter 1, subchapter H, Part 888.
