01-065 Total Joint Arthroplasty Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part A total joint arthroplasty billed on dates of service from January 1, 2019, through December 31, 2019. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Joint replacement surgery, also known as arthroplasty, has proven to be an important medical advancement. Arthroplasty is most performed on the hip and knee joints with the goal being to relieve pain and improve or increase the functional activity of the beneficiary. The Medicare Severity Diagnosis Related Group (MS-DRG) is a system used to classify various diagnoses and procedures for inpatient hospital stays so that Medicare can accurately reimburse the hospital under the inpatient prospective payment system (IPPS). In 2020, the Comprehensive Error Rate Testing (CERT) noted a 19.4% improper payment rate for major hip and knee replacement or reattachment of lower extremity (MS-DRGs 469 and 470).

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical record review of total joint arthroplasty claims. The SMRC will perform medical record review on supporting documentation to determine if total hip and/or knee arthroplasty was reasonable and necessary and to validate that the appropriate MS-DRG assignment is present on the claim.

Claim Sample Detail

TOB MS-DRG
11x
  • 469: MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT
  • 470: MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collection and submitting pertinent information to decrease provider burden.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

  1. Operative/procedure report of the service billed
  2. Description of the device used in the procedure
  3. Admission initial assessment
  4. History and Physical reports (include medical history and current list of medications)
  5. Documentation of pain level and activities of daily living (ADL) limitations
  6. Medical record documentation that describes and supports other treatment(s)/medication(s) was tried and failed or was considered and ruled out
  7. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
  8. X-ray findings and/or bone cultures
  9. Beneficiary’s medical records (which may include practitioner medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the service(s) provided is/are reasonable and necessary
  10. Discharge summary from Hospital, Skilled Nursing, Continuous Care, and/or Respite Care facilities
  11. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  12. Documentation to support the medical necessity of service and DRG billed
  13. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services
  14. Advance Beneficiary Notice of Liability (ABN); if applicable
  15. Any other supporting documentation
  16. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  17. PLEASE NOTE: It is the responsibility of the supplier/provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met

References/Resources

  • Social Security Act (SSA) Title XVIII, § 1812 Scope of Benefits
  • SSA Title XVIII, § 1815(a) Providers Must Furnish Information
  • SSA Title XVIII, § 1833(e) Payment of Benefits
  • SSA Title XVIII § 1861(s)(8) Part E – Miscellaneous Provisions
  • SSA Title XVIII, § 1862(a)(1)(A) Exclusions from Coverage and Medicare as Secondary Payer
  • SSA Title XVIII, § 1879(a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • SSA Title XVIII, §1886 Payment to Hospitals for Inpatient Hospital Services
  • SSA Title XVIII, 1893 (f)(7)(A)(B) (i-iv) Medicare Integrity Program
  • Code of Federal Regulations (CFR) Title 21, Chapter I, Subchapter H, Part 888. Orthopedic Devices
  • CFR Title 42 § 400.200. General Definitions
  • CFR Title 42 § 412.1(a)(1). Scope of Part
  • CFR Title 42 § 412.2. Basis of payment
  • CFR Title 42 § 424.5(a)(6). Basic Conditions
  • CFR Title 42 § 482.21 Documentation for Medical Records
  • CFR Title 42 § 482.24(c)(1). Condition of Participation: Medical Record Services
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 1, § 80.3.2.2. Consistency Edits for Institutional Claims
  • MCPM, Publication 100-04, Chapter 23, §10.2. Inpatient Claim Diagnosis Reporting
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, § 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • MPIM, Publication 100-08, Chapter 3, § 3.2.3.2 Time Frames for Submission
  • MPIM, Publication 100-08, Chapter 3, § 3.3.2.4. Signature Requirements
  • MPIM, Publication 100-08, Chapter 3, §3.4.1.3. Diagnosis Code Requirements
  • MPIM, Publication 100-08, Chapter 3, § 3.6.2.1. Coverage Determinations
  • MPIM, Publication 100-08, Chapter 3, § 3.6.2.2. Reasonable and Necessary Criteria
  • MPIM, Publication 100-08, Chapter 3, § 3.6.2.4. Coding Determinations
  • MPIM, Publication 100-08, Chapter 3, § 3.6.2.5. Denial Types
  • MPIM, Publication 100-08, Chapter 6, § 6.5.3. DRG Validation Review
  • MPIM, Publication 100-08, Chapter 6, § 6.5.4. Review of Procedures Affecting the DRG
  • MPIM, Publication 100-08, Chapter 13, § 13.5.4. Reasonable and Necessary Provisions in LCDs
  • Local Coverage Determination (LCD) L33456, Total joint Arthroplasty
  • LCD L33618, Major Joint Replacement (Hip and Knee)
  • LCD L34163, Total Hip Arthroplasty
  • LCD L36007, Lower Extremity Major Joint Replacement
  • LCD L36039, Total Joint Arthroplasty
  • LCD L36573, Total Hip Arthroplasty
  • LCD L36575, Total Knee Arthroplasty
  • LCD L36577, Total Knee Arthroplasty
  • Local Coverage Article (LCA) A51683, Billing and Coding: Total Hip Arthroplasty
  • LCA A51685, Billing and Coding: Total Knee Arthroplasty
  • LCA A56777, Billing and Coding: Total Joint Arthroplasty
  • LCA A56796, Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee)
  • LCA A57428, Billing and Coding: Total Joint Arthroplasty
  • LCA A57684, Billing and Coding: Total Hip Arthroplasty
  • LCA A57686, Billing and Coding: Total Knee Arthroplasty
  • LCA A57765, Billing and Coding: Major Joint Replacement (Hip and Knee)

Last Updated Feb 16, 2022