Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), has conducted a post-payment review of claims for Medicare Part A billed on dates of service from January 1, 2019, through December 31, 2019. Below are the review results:

Background

Joint replacement surgery, also known as arthroplasty, has proven to be an important medical advancement. Arthroplasty is most often performed on the hip and knee joints, with the goal being to relieve pain and improve or increase the functional activity of the beneficiary. The Medicare Severity Diagnosis Related Group (MS-DRG) is a system used to classify various diagnoses and procedures for inpatient hospital stays so that Medicare can accurately reimburse the hospital under the inpatient prospective payment system (IPPS). In 2020, the Comprehensive Error Rate Testing (CERT) noted a 19.4% improper payment rate for major hip and knee replacement or reattachment of lower extremity (MS-DRGs 469 and 470).

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical record review of total joint arthroplasty claims. The SMRC has perform medical record review on supporting documentation to determine if total hip and/or knee arthroplasty was reasonable and necessary and to validate that the appropriate MS-DRG assignment is present on the claim.

Common Reasons for Denial

• No Response to the Documentation Request
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely.
• Medical Necessity
  • The Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(a), provides the guidance that: “No payment may be made under Part A or Part B for any expenses incurred for items or services which, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

Claims were denied when submitted documentation did not support the requirements in applicable Local Coverage Determination (LCD). Documentation did not contain medical records such as conventional radiological or MRI evidence to support advanced joint arthritis and/or unsuccessful conservative therapy.

• Incomplete and/or Insufficient Documentation
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. Documentation submitted was not sufficient to support medical necessity.

Resources

Social Security Act (SSA) Title XVIII

• § 1812 Scope of Benefits
• § 1815(a) Providers Must Furnish Information
• § 1833(e) Payment of Benefits
• § 1861(s)(8) Part E – Miscellaneous Provisions
• § 1862(a)(1)(A) Exclusions from Coverage and Medicare as Secondary Payer
• § 1879(a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• §1886 Payment to Hospitals for Inpatient Hospital Services
• §1893 (f)(7)(A)(B) (i-iv) Medicare Integrity Program

Code of Federal Regulations (CFR) Title 21

• Ch I, § H, Part 888. Orthopedic Devices

CFR Title 42

• § 400.200 General Definitions
• § 412.1(a)(1) Scope of Part
• § 412.2 Basis of Payment
• § 424.5(a)(6) Basic Condition
• § 482.21 Documentation for Medical Records
• § 482.24(c)(1) Condition of Participation: Medical Record Services

Medicare Claims Processing Manual (MCPM), Publication 100-04

• Ch. 1, § 80.3.2.2 Consistency Edits for Institutional Claims
• Ch. 23, §10.2 Inpatient Claim Diagnosis Reporting

Medicare Program Integrity Manual (MPIM), Publication 100-08

• Ch. 3, § 3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
• Ch. 3, § 3.2. 3 Time Frames for Submission
• Ch. 3, § 3.3.2.4 Signature Requirements
• Ch. 3, §3.4.1.3 Diagnosis Code Requirements
• Ch. 3, § 3.6.2.1 Coverage Determinations
• Ch. 3, § 3.6.2.2 Reasonable and Necessary Criteria
• Ch. 3, § 3.6.2.4 Coding Determinations
• Ch. 3, § 3.6.2 Denial Types
• Ch. 6, § 6.5.3 DRG Validation Review
• Ch. 6, § 6.5.4 Review of Procedures Affecting the DRG
• Ch. 13, § 13.5.4 Reasonable and Necessary Provisions in LCD

Local Coverage Determination (LCD)

• L33456 Total Joint Arthroplasty
• L33618 Major Joint Replacement (Hip and Knee)
• L34163 Total Hip Arthroplasty
• L36007 Lower Extremity Major Joint Replacement
• L36039 Total Joint Arthroplasty
• L36573 Total Hip Arthroplasty
• L36575 Total Knee Arthroplasty
• L36577 Total Knee Arthroplasty

Local Coverage Article (LCA)

• A51683 Billing and Coding: Total Hip Arthroplasty
• A51685 Billing and Coding: Total Knee Arthroplasty
• A56777 Billing and Coding: Total Joint Arthroplasty.
• A56796 Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee)
• A57428 Billing and Coding: Total Joint Arthroplasty
• A57684 Billing and Coding: Total Hip Arthroplasty
• A57686 Billing and Coding: Total Knee Arthroplasty
• A57765 Billing and Coding: Major Joint Replacement (Hip and Knee)

Other

• Medicare Learning Network (MLN) ICN909065, Major Joint Replacement (Hip or Knee)

Last Updated Jan 26, 2023