Major Joint Replacement


RAC Region C contractor Connolly posted a condition of coverage review for both Inpatient and Physician providers on October 23, 2013, regarding major joint replacement. The description posted on Connolly’s site describes the issue:

“Major joint replacement is reserved for patients whose symptoms have not responded to other treatments. The goal of the surgery is to relieve pain and improve or increase patient function. Medical documentation will be reviewed to determine if the major joint replacement was reasonable and necessary for the patient.”

In a 2011 Comprehensive Error Rate Testing (CERT) report from the Centers for Medicare & Medicaid Services (CMS), major joint replacements were cited as follows: The services related to major joint replacements had an improper payment rate of 11.5 percent, accounting for 2.1 percent of the overall Medicare FFS improper payment rate. The projected improper payment amount for joint replacements during the 2011 report period was approximately $686.7 million.

As a result of the CERT report, CMS further requires sufficient documentation for major joint replacement.

One of the references Connolly sites for this issue is CMS’ MedLearn Matters article #SE1236, “Documenting Medical Necessity for Major Joint Replacement (Hip and Knee).”

The following document types often provide the information needed to support the medical necessity of a total joint replacement, but are frequently missing from the submitted record. This list is not exhaustive; it is a sample.


  • Description of the pain (onset, duration, character, aggravating, and relieving factors)
  • Limitation of Activities of Daily Living (ADLs) – specify
  • Safety issues (e.g. falls)
  • Contraindications to non-surgical treatments
  • Listing and description of failed nonsurgical treatments such as:
    • Trial of medications (e.g. NSAIDs)
    • Weight loss
    • Physical therapy
    • Intra-articular injections
    • Braces, orthotics, or assistive devices

Physical Examination:

  • Deformity
  • Range of motion
  • Crepitus
  • Effusions
  • Tenderness
  • Gait description


Results of applicable investigations (e.g. plain radiographs). Document the findings.

Clinical Judgment:

  • Reasons for deviating from a stepped-care approach.

Example of Documentation Demonstrating Medical Necessity for Joint Replacement


A. The hospital record for the preoperative joint replacement surgical patient includes:


  • Present illness from onset until the present
  • Current symptoms and functional limitations
  • Outcomes of nonsurgical treatments, such as:
    • Medications e.g., anti-inflammatory medication, analgesics
    • Intra-articular injections
    • Physical therapy and/or home exercise plans
    • Assistive devices e.g., cane, walker, braces (specify type of brace), orthotics
  • Comorbidities.

Physical Examination:

  • Joint examination with detailed objective findings.


  • Preoperative imaging studies.

The hospital record for the joint replacement surgical patient includes documentation of specific conditions. For example:

  • Osteoarthritis (mild, moderate, severe)
  • Inflammatory arthritis (e.g., rheumatoid arthritis, psoriatic arthritis)
  • Failure of previous osteotomy
  • Malignancy of distal femur, proximal tibia, knee joint, soft tissues
  • Failure of previous unicompartmental knee replacement
  • Avascular necrosis of knee
  • Malignancy of the pelvis or proximal femur or soft tissues of the hip
  • Avascular necrosis of the femoral head
  • Fractures (e.g., distal femur, femoral neck, acetabulum)
  • Nonunion, malunion, or failure of previous hip fracture surgery
  • Osteonecrosis

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