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February 24, 2015

Major Joint Replacement (DRG 470): Documenting Conservative Treatments and Medical Necessity

Reducing Medicare payment errors is a major focus for CMS and its contractors, including CGS. This effort has prompted several auditing projects designed to identify and recover improper payments, many of which are due to documentation errors. Major joint replacement procedures are one area of focus, for which inaccurate and incomplete information has resulted in provider overpayments. CMS recognizes that joint replacement surgery is reserved for patients whose symptoms have not responded to conservative treatments. Crucial information clearly outlining why the procedure is medically necessary is often missing from joint replacement documentation.

To avoid denial of claims for major joint replacement surgery, the medical records should contain enough detailed information to support the determination that major joint replacement surgery was reasonable and necessary for the patient. The major area of concern in reviews of these services is a lack of documentation related to conservative treatments and the patient's responses to those treatments. Documentation should tell the patient's story and clearly describe how he or she has reached the point of needing a replacement hip, shoulder, or knee. This includes:

  • History and physical
  • Operative note
  • Pre-surgical x-ray reports
  • Nursing admission assessment
  • Physician office notes and physical/occupational therapy evaluation with attention to the patient's prior functional status, some of which may be obtained from the referring physician
  • Explain what the patient has experienced – e.g., falls, inability to walk up three steps to the front door, allergic reactions to NSAIDs, changes in activities of daily living and inability to participate in recreational activities due to pain and instability of the joint.
  • Include the patient's description of their pain and how it affects them. Describe the physical exam of the affected joint – discuss range of motion, effusions, crepitus, deformity, and tenderness of the joint.
  • Specifically address certain treatment modalities – if the patient received intra-articular injections prior to surgery, discuss how many, how often, and how the patient responded to each.
  • Identify the NSAIDs the patient has tried and the results.
  • Pre-surgical physical therapy progress notes are important in demonstrating how the patient has progressively worsened over a period of time. Noting that the patient has "failed conservative therapies" in the history and physical is a conclusive statement and should be supported by other specific, objective information in the patient's medical record.

More about Documenting Conservative Treatment

There may not always be sufficient documentation of conservative treatments; for example, in cases of progressively destructive diseases such as avascular necrosis or traumatic injuries to the joint, conservative treatment is not an option. Defining conservative treatment varies based on the patient's pre-surgical condition.

  • There should be documentation of loss of range of motion, the effect on activities of daily living, and use of any assistive devices.
  • There should also be x-rays to show joint subluxation, joint-space narrowing, and presence of sub-chondral cysts.
  • The documentation needs to be detailed enough that reviewers will be able to distinguish a definite progression in the disease process and determine medical necessity for the procedure.

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