Billing and Coding: Major Joint Replacement (Hip and Knee)

Social Security Act (Title XVIII) Standard References:

• Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33618 Major Joint Replacement (Hip and Knee). Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Bilateral knee or hip replacement surgery during the same encounter is subject to bilateral pricing. Generally, there are two surgeons acting as co-surgeons, with each one operating on a distinct knee or hip. Modifier – 50 (bilateral procedure) and – 62 (co-surgeon) should be appended to the appropriate CPT procedure code.

RT and LT modifiers should be used as appropriate.

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. 

Documentation Requirements

1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
4. 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: a) subchondral cysts, b) subchondral sclerosis, c) periarticular osteophytes, d) joint subluxation, e) joint space narrowing, or f) avascular necrosis.
   • Pain or functional disability at the hip or knee. For example, documented pain that interferes with ADLs (functional disability), or pain that is increased with initiation of activities or pain that increases with weight bearing.
   • Unsuccessful conservative therapy (non-surgical medical management). The documentation should demonstrate a history of a reasonable attempt (usually 3 months or more) at conservative therapy as appropriate for the patient in their current episode of care. For example, documented trial of NSAIDs or contraindication to such therapy and/or documented supervised physical therapy. Documentation should support that ADLs are diminished due to pain and/or disability despite non-surgical medical management.
   • For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKA or THA should be appropriately addressed in the medical record.
5. 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).
• Pain at the hip or knee when indicated as a reason for the procedure (e.g., for revision/replacement TKA/THA). For example, documented pain that interferes with ADLs functional disability), pain that is increased with initiation of activities or pain that increases with weight bearing.
• For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as 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 documented 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. 
6. In the instance that the patient is undergoing a bilateral knee or hip replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing THA or TKA bilaterally.
7. If in certain circumstances the patient does not meet all of the required criteria outlined in the local coverage determination (LCD) for a procedure, but the treating physician feels that the procedure is a covered procedure given the current standards of care, then the documentation must clearly outline the patient’s episode of care that supports the major procedure and must clearly address the reason(s) for coverage. For example, if clinical findings (or lack of) for an indication are not consistent with the LCD criteria, it should be directly addressed in the pre procedure documentation. For example, if certain conservative measures are not necessary 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.