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August 6, 2018

Major Joint Replacement (DRG 470): Preventing Denials

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 review of these services is a lack of documentation related to conservative treatments and the patient's responses to those treatments. Documentation should provide a detailed description of why the procedure is required, inclusive of the patient's course of treatment that has transpired, which has lead to the need for the procedure.

This includes:

  • History and physical
  • Operative note
  • Pre-surgical x-ray reports/imaging studies
  • 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., safety issues such as falls, specific changes or limitations in Activities of Daily Living (ADLs) e.g., inability to walk up three steps to the front door, inability to participate in recreational activities due to pain and instability of the joint, and has an allergic reaction to NSAIDs.
  • Include the patient's description of their pain (onset, duration, character, aggravating, and relieving factors), and how the patient is impacted. Describe the physical exam of the affected joint – discuss range of motion, effusions, crepitus, deformity, description of gait, and tenderness of the joint.
  • Specifically address non-surgical treatment modalities tried and failed, including duration and response – e.g., medication trial, weight loss, physical therapy, intra-articular injections, braces, or assistive devices – if the patient received intra-articular injections prior to surgery, discuss how many, how often, and how the patient responded to each.
  • Trial of medications – e.g.,identify the NSAIDs (including dosage and duration) the patient has tried and the results or an intolerance/allergic reaction to a medication.
  • 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 accompanied by specific objective information of the conservative treatments tried and failed and the patient's responses to those treatments in the medical record or contraindications to non-surgical treatments.

When Conservative Treatment is Not an Option:

There may not always be sufficient documentation of conservative treatments; for example, in cases of progressively destructive diseases such as avascular necrosis, traumatic injuries to the joint, or where pain is progressive, severe and not controlled by medication. New onset of a complete inability to ambulate in a patient undergoing conservative treatment may also indicate a need for urgent joint replacement. Documentation must support the rationale for more urgent joint replacement.

  • 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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