Total Joint Arthroplasty
Insufficient documentation causes most improper payments. Insufficient documentation means that something was missing from the medical records.
Providers can help prevent CERT errors on total joint arthroplasty by ensuring the medical record contains documentation that fully supports the medical necessity and justification of the procedure performed.
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 nonsurgical 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 nonsurgical medical management typically includes one or more of the following:
- anti-inflammatory medications and/or analgesics;
- flexibility and muscle strengthening exercises;
- supervised physical therapy;
- assistive device use;
- reasonable activity restrictions;
- weight reduction as appropriate;
- therapeutic injections into the joint as appropriate.
Nonsurgical medical management may be inappropriate, ineffective or counterproductive when one or more of the following is present:
- bone on bone articulation;
- severe deformity;
- severe pain (particularly at rest) and significant disabling interference with activities of daily living.
Related Content
- Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 110.1 C (Provider Retention of Health Insurance Records/Medical Record Material)
- CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (Signature Requirements)
- CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5 (Medical Review of Inpatient Hospital Claims Part A Payment) and Section 6.5.3 (DRG Validation Review)
- Billing and Coding Article: Total Joint Arthroplasty (A57428)
- National Government Services Local Coverage Determinations (LCD) & Articles