Billing and Coding: Total Knee Arthroplasty

The following billing and coding guidance is to be used with its associated Local Coverage Determination. Documentation Requirements In order to qualify for coverage of both Medicare Part A inpatient services and Part B provider services the medical record must contain documentation that fully supports the medical necessity and justification of the procedure performed and must be made available to Noridian upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary. A history and physical, discharge summary, physician progress notes and an operative report are typically in the hospital record for the procedures in this LCD. Other relevant information addressing coverage criteria related to the patient’s episode of care prior to the hospitalization, should be included in the hospital record (see below). Failure to include this information in the hospital record may result in denial of coverage for Part A services and trigger a review of the Part B provider claim to determine whether the Part B service rendered was reasonable and necessary. When the procedure is indicated for advanced joint disease, the following should be documented in the medical record: • Arthritis of the knee supported by X-ray, MRI, or CT. The X-ray, MRI or CT, as medically necessary, should demonstrate and the provider must document one or more of the following: a) subchondral cysts, b) subchondral sclerosis, c) periarticular osteophytes, d) joint subluxation, e) the degree of joint space narrowing, f) avascular necrosis or g) bone on bone articulations • Pain or functional disability at the knee. Pain and/or functional disability should be described in context. For example, documented pain that interferes with ADLs (functional disability), or pain that is increased with initiation of activities or pain that increases with weight bearing. • Unsuccessful conservative therapy (non-surgical medical management) if appropriate. The documentation should demonstrate a history of a reasonable attempt at conservative therapy as appropriate for the patient in his/her current episode of care. For example, documented trial of NSAIDs or contraindication to such therapy and/or documented supervised physical therapy. Documentation should support that ADLs are diminished due to pain and/or disability despite non-surgical medical management. • For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKA should be appropriately addressed in the medical record. Medical record documentation for other TKR/TKA indications outlined in the LCD should include the following, when indicated: • Supporting evidence (e.g., pathology reports and referral from an Oncologist for a malignancy of the joint or X-ray of a fracture). • Pain at the knee when indicated as a reason for the procedure (e.g., for revision/replacement TKR/TKA). For example, documented pain that interferes with ADLs (functional disability), pain that is increased with initiation of activities or pain that increases with weight bearing. • For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKR/TKA should be appropriately addressed in the medical record. • When infection is the reason for revision TKR/TKA surgery, laboratory and/or pathology reports must be in the medical record and all documentation regarding treatment of the infection and a physician note indicating that it is appropriate to proceed with surgery should be in the medical record as well. In the instance that the patient is undergoing a bilateral knee replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing a bilateral TKR/TKA. The treating physician must discuss the significant benefit and risks with the patient. In order to meet Medicare’s reasonable and necessary (R&N) threshold for coverage of a procedure, the physician’s documentation for the case should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need and is at least as beneficial as existing alternatives & the procedure is furnished with accepted standards of medical practice in a setting appropriate for the patient’s medical needs and condition). Lacking compelling arguments for an exception in the supporting documentation, the hospital and physician services can be denied. If in certain circumstances the patient does not meet all of the required criteria outlined in the local coverage determination (LCD) for a procedure, but the treating physician feels that the procedure is a covered procedure given the current standards of care, then the documentation must clearly outline the patient’s episode of care that supports the major procedure and must clearly address the reason(s) for coverage. For example, if clinical findings (or lack of) for an indication are not consistent with the LCD criteria, it should be directly addressed in the pre-procedure documentation. For example, if certain conservative measures are not necessary or appropriate for a given patient, it should be directly noted in the pre-procedure documentation. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre-procedure record and if consistent with the episode of care for the patient as documented in patient records and claim history. Review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis.