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
- Range of motion
- Gait description
Results of applicable investigations (e.g. plain radiographs). Document the findings.
- 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
- 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
B. The hospital record for the postoperative joint replacement surgical patient includes:
- Operative report for the procedure, including observed pathology
- Daily progress notes for inpatients
- Discharge plan and discharge orders
Example of a medical record that may result in a DENIED claim
Mrs. Smith is a female, age 70, with chronic right knee pain. She states she is unable to walk without pain and pain meds do not work. Therefore, she needs a total right knee replacement.
Example of a medical record with more detail and support of medical necessity
Mrs. Smith is a 70-year-old female who is suffering from end-stage Osteoarthritis (OA) of her right knee, worsening gradually over the past 10 years. Treatment has included NSAIDs which have not effectively relieved her pain/inflammation and which have recently begun to cause her gastric distress. She has also participated in an exercise program/physical therapy for the past 3 months without functional improvement. Sometimes the pain keeps her awake at night. She is using a cane and is no longer able to climb the five steps to her front door. Personal safety is compromised as she had falls x 3 in attempting the stairs to her home entrance. Her knee pain and stiffness limit her ability to perform ADLs. She cannot walk from her bedroom to her kitchen without stopping to rest.
Vital Signs: 140/90, Heart rate 78, RR 18.
Physical exam: Bilateral varus knee deformity consistent with severe osteoarthritis. Right knee extension reduced to minus 15 degrees and flexion to less than 100 degrees. Unable to rise from chair unassisted. Full motion of the right hip, no calf tenderness or ankle edema. Antalgic gait noted.
X-ray (7/2/11): Right knee shows joint space narrowing along with marginal osteophytes.
Total Knee Arthroplasty (TKA) indicated.
Discussed risks and benefits of total joint replacement with patient. Patient understands both.
Admit to inpatient care for right TKA. Forward a copy of this note to include in patient’s chart along with a copy of the patient’s x-ray reports.
RAC issues for the week of November 4 – November 8, 2013:
RAC Region C Connolly
- Medical Necessity - Condition of Coverage Review: Major Joint Replacement - IP - C004072013 - 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.
- Medical Necessity - Condition of Coverage Review: Major Joint Replacement - Carrier - C004092013 - 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.
About the Author
Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payers.
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