Knowledge Base Article

Total Knee Procedures (CPT 27447) were removed from the Medicare Inpatient Only List Effective January 1, 2018. CMS also finalized prohibiting RAC “reviews for patient status for TKA procedures performed in the inpatient setting for a period of 2 years to allow time and experience for these procedures under this setting.” However, these procedures remain “fair game” for review for medical necessity of the surgical procedure regardless of patient status.

CMS’s January 11, 2018 edition of MLN Connects included a new Medicare Learning Network (MLN) publication titled Major Joint Replacement (Hip or Knee) Booklet (ICN 909065).  This booklet provides guidance on how to document medical necessity; ensure a complete and accurate medical record; key points for billing codes; and aids to correct billing.

CMS Focuses on Major Joint Replacement or Reattachment

Before the “how to,” it is important to understand “why” the focus on Major Joint Replacements. 

Major Joint Replacement or Reattachment (MS-DRGs 469 and 470) are high volume, high cost procedures for Medicare. CMS has had Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs) review claims for these MS-DRGs. “Their findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.”

MS-DRG 470 is consistently the top surgical MS-DRG by volume for hospitals. To illustrate the volume and cost, the following table details the Jurisdiction J (JJ) MAC paid claims data for MS-DRG 470 for dates of service from July 1, 2016 through June 30, 2017.

‍Document Medical Necessity

CMS notes that “to avoid denial of claims…the medical records should contain enough detailed information to support the determination that major joint replacement surgery was reasonable and necessary for the patient. Progress notes should consist of more than just conclusive statements. Therefore, the medical record of the joint replacement surgical patient must specifically document a complete description of the patient’s historical and clinical findings.”

The Patient’s Medical Record

The following information should be included in a patient’s Medical Record to support that surgery was reasonable and necessary for the patient.

Patient History

The history should include information such as:

• A description of pain (onset, duration, character, aggravating, and relieving factors),
• Any limitations of specific Activities of ADLs (e.g., unable to climb steps),
• Safety issues (e.g. any falls),
• Contraindications to non-surgical treatments,
• Failed non-surgical treatments (e.g., NSAIDs, weight loss, intra-articular injections).

Physical Exam

Detailed objective findings of the joint examination should be included in the physical exam. Examples of findings include:

• Any deformity,
• Range of motion limitations,
• Crepitus,
• Effusions,
• Tenderness, and
• Gait description.

Investigations

The medical record should include the results of any applicable tests (i.e. plain radiographs and pre-operative imaging studies).

The Patient’s Hospital Record

Pre-operatively, the record should include documentation of the specific condition necessitating surgery such as osteoarthritis (mild, moderate, severe), avascular necrosis of the knee, or fractures).

Post-Operatively, the record should include the operative report (including observed pathology), daily progress notes for an inpatient, the discharge plan and discharge orders.

The booklet goes on to provide examples of a medical record that may result in a denied claim and a claim with more detail and support of medical necessity. CMS also provides a link to MLN SE1236 - Documenting Medical Necessity for Major Joint Replacement (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se1236.pdf) as a resource for providing guidance on documenting medical necessity for major joint replacement procedures.

MMP encourages you to carefully read the MLN Booklet and MLN SE1236 and share this information with your surgeons as CMS notes that “both physicians and hospitals are responsible for ensuring a complete and accurate record.”