Billing and Coding: Total Joint Arthroplasty

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L40232 Total Joint Arthroplasty. Please refer to the LCD for reasonable and necessary requirements. Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported. Bilateral surgery Bilateral knee or hip replacement surgery during the same encounter is subject to bilateral pricing. Generally, there are 2 surgeons acting as co-surgeons, with each one operating on a distinct knee or hip. Modifier – 50 (bilateral procedure) and – 62 (co-surgeon) should be appended to the appropriate CPT procedure code. RT and LT modifiers should be used as appropriate. Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Documentation Requirements All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. Documentation Requirements When the procedure is indicated for advanced joint disease, the following should be documented in the medical record: Arthritis of the knee or hip supported by X-ray or alternate imaging such as MRI or CT. The imaging should demonstrate one of the following: a) subchondral cysts, b) subchondral sclerosis, c) periarticular osteophytes, d) joint subluxation, e) joint space narrowing, f) avascular necrosis or bone on bone articulations. The extent to which pain or functional disability interferes with ADLs (functional disability), increases with activity or increases with weight bearing. ADLs include, but are not limited to, dressing, feeding, toileting, grooming, physical ambulation (including balance/risk of falls), and bathing. This must be measured using a standardized scale for pain or function. Unsuccessful conservative therapy (non-surgical medical management). The documentation should demonstrate a history of a reasonable attempt (usually 3 months or more) at conservative therapy as appropriate for the patient in their current episode of care. Clinically appropriate non-surgical medical management typically includes one or more of the following: anti-inflammatory medications and/or analgesics; and/or flexibility and muscle strengthening exercises; and/or supervised physical therapy; and/or assistive device use; and/or reasonable activity restrictions; and/or weight reduction as appropriate; and/or therapeutic injections into the joint as appropriate. Risk reduction measures including: Documentation of smoking history and counselling on smoking cessation and treatment if applicable. If diabetic coordination with treating physician to optimize diabetes control prior to surgical intervention. Documentation of discussion of risk associated with diabetes and alternative treatments. If obese, counseling of risk and efforts for weight reduction to optimize outcomes documented. Non-surgical medical management may be inappropriate, ineffective or counterproductive when one or more of the following is present: bone on bone articulation; and/or severe deformity; and/or Severe pain (particularly at rest) and significant disabling interference with activities of daily living (ADL). For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as Total Knee Arthroplasty (TKA) or total hip arthroplasty (THA) should be appropriately addressed in the medical record. Medical record documentation for other TKA and THA 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 hip or knee when indicated as a reason for the procedure. 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, such as but not limited to coronary artery disease or obstructive pulmonary disease, the risk/benefit of the TKA or THA procedure should be appropriately addressed in the medical record. When infection is the reason for revision TKA or THA surgery, laboratory and/or pathology reports must be documented 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 or hip replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing THA or TKA bilaterally. 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 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. Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity. The devices/implants utilized for total knee and total hip replacement surgeries are regulated by the FDA as medical devices. The devices used should be class II or class III devices that meet the requirements outlined in CFR 21, Chapter 1, subchapter H, Part 888.