Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid (CMS), conducted post-payment review of claims for Medicare Part A billed for total knee arthroplasty or total knee revision on dates of service from January 1, 2023 through June 30, 2025. This notification includes the reasons for the review, documentation that was requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims. Below are the review results:

Background

Joint replacement surgery, known as arthroplasty, is a major advancement in orthopedic medicine. The most frequently replaced joints are the hips and knees. The knee, being the largest joint in the body, is comprised of the distal femur, proximal tibia, and patella. It is divided into three compartments: medial, lateral, and patellofemoral; each lined with cartilage and enclosed by synovial fluid, which facilitates smooth movement.

Arthritis, including osteoarthritis, rheumatoid arthritis, and traumatic arthritis, is the leading reason for a total knee replacement. These conditions cause significant pain and limit daily activities like walking, squatting, and climbing stairs. Other indications for surgery include persistent swelling, stiffness, inadequate relief from medications, failed conservative treatment, osteonecrosis, and malignancy. The primary goals of knee replacement are pain relief and improved function. Sometimes, a revision surgery is needed due to persistent pain or declining function from issues such as infection, bone loss, fracture, loosening, or wear of the prosthesis.

Reason for Review

The SMRC was tasked to perform data analysis and conduct medical record reviews on claims billed with Diagnosis Related Group (DRG) codes specific to lower extremity joint replacements or revisions and Internal Classifications of Diseases-10 (ICD-10) Procedure codes for total knee joint replacements or revisions billed with dates of service January 1, 2023 through June 30, 2025. Medical record review was performed on supporting documentation to determine if the total knee arthroplasty service or total knee revision performed in a hospital inpatient setting was reasonable, necessary, and billed appropriately.

The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Non-Response to the Additional Documentation Request (ADR)
  • No medical record documentation was received. Refer to Internet-only Manual Pub 100-08, Chapter 3, Section 3.2.3.8, 42 CFR 424.5(a)(6) and Social Security Act Title XVIII, Section 1815(a), 1833(e), and 1862(a)(1)(A). This requires providers to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was either not submitted or not submitted timely to support the claim, as requested by the ADR.
• Incomplete or Insufficient Documentation
  • The documentation was incomplete and/or insufficient. Refer to Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C, Social Security Act 1833(e), 42 CFR 424.5(a)(6). Claims were denied when the medical record was found to be incomplete or missing required elements as outlined in the appropriate coverage policy. This includes, but not limited to, missing operative notes, pre-procedural radiographic evidence of advanced joint disease, or history and physical documentation detailing functional impairment, pain, and prior conservative treatment.
• Documentation Did Not Support Medical Necessity
  • The documentation submitted did not support medical necessity as listed in coverage requirements in the Local Coverage Determination (LCD). Refer to Social Security Act 1862(a)(1)(A), Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.1, 3.2.2.2. Claims were denied for medical necessity when the documentation did not support the covered indications outlined in the associated LCD.

References

Social Security Act (SSA), Title XI

• §1135 Authority to Waive Requirements During National Emergencies

SSA, Title XVIII

• §1815(a) Payment to Providers of Services
• §1833(e) Payment of Benefits
• §1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• §1877(g) Blanket Waivers of Section 1877(G) of the Social Security Act Due to Declaration of COVID-19 Outbreak in the United States as a National Emergency
• §1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• §1886 Payment to Hospitals for Inpatient Hospital Services
• §1893 Medicare Integrity Program

42 Code of Federal Regulations (CFR)

• §411.15(k)(1) Particular services excluded from coverage
• §412.2 Basis of payment
• §424.5(a)(6) Basic Conditions

Federal Register

• Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov)
• Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency. CMS-1744-IFC. Effective March 1, 2020. Retrieved from CMS-1744-IFC

Internet-Only Manual (IOM), Publication (Pub.) 100-04, Medicare Claims Processing Manual (MCPM)

• Chapter (Ch.) 1 General Billing Requirements
• Ch. 12, §40 Surgeons and Global Surgery
• Ch. 23, §10.2 Inpatient Claim Diagnosis Reporting
• Ch. 30, §50 Advance Beneficiary Notice of Non-coverage (ABN)

IOM, Pub. 100-08, Medicare Program Integrity Manual (MPIM)

• Ch. 3, §3.2.3.3 Third-party Additional Documentation Request
• Ch. 3, §3.2.3.4 Additional Documentation Request Required and Optional Elements
• Ch. 3, §3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
• Ch. 3, §3.3.2.1 Documents on which to Base a Determination
• Ch. 3, §3.3.2.4 Signature Requirements
• Ch. 3, §3.3.3 Reviewing Claims in the Absence of Policies and Guidelines
• 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, §3.6.2.3 Limitation of Liability Determinations
• Ch. 3, §3.6.2.4 Coding Determinations
• Ch. 3, §3.6.2.5 Denial Types
• Ch. 13, §13.5.4 Reasonable and Necessary Provisions in LCDs

Local Coverage Determination (LCD)

• L33456 Total Joint Arthroplasty
• L33618 Major Joint Replacement (Hip and Knee)
• L36007 Lower Extremity Major Joint Replacement
• L36039 Total Joint Arthroplasty
• L36575 Total Knee Arthroplasty
• L36577 Total Knee Arthroplasty
• L39911 Total Joint Arthroplasty. Effective October 13, 2024

Local Coverage Article (LCA)

• 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
• A57685 Billing and Coding: Total Hip Arthroplasty
• A57686 Billing and Coding: Total Knee Arthroplasty
• A57765 Billing and Coding: Major Joint Replacement (Hip and Knee)
• A59811 Billing and Coding: Total Joint Arthroplasty. Effective October 13, 2024

Last Updated Jul 28, 2026