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Last Modified: 2/12/2024 Location: FL, PR, USVI Business: Part A, Part B

Total knee arthroplasty

First Coast has identified total knee arthroplasty (TKA), also known as knee replacement services, CPT 27445, 27447, 27486 and 27487, as a top claim denial for claims reviewed by the Recovery Audit Contractor during 2021. The main category of error resulting in denials was medical necessity and documentation requirements. This medical review applies to the following provider types: hospital, outpatient, and ambulatory surgical center.

Documenting medical necessity to avoid denials of claims

To avoid denials of claims for major joint replacement surgery, medical records should contain enough detailed information to support the determination that major joint replacement surgery was reasonable and necessary.
The goal of total knee replacement surgery is to relieve pain and improve or increase function for patients with arthritis of the knee disease including osteoarthritis, rheumatoid arthritis, and traumatic arthritis. Other reasons to perform a TKA are osteonecrosis and malignancy. Occasionally, there may be a need for a total knee revision in which it is important to provide a replacement of the components of the previous surgery responsible for the failure. To verify a complete list of medical necessity criteria, please refer to the coverage guidelines in our LCD L33618 Major joint replacement (hip and knee) external link.
Please note that if you receive an additional documentation request or ADR, you must submit sufficient documentation to demonstrate the medical necessity of the service provided. Here’s some tips when responding to an ADR:
• Documentation must be legible and include patient identification and date(s) of service
• Legible signature of the physician or non-physician practitioner who provided the service(s) must be present
• The medical record must support the ICD10 CM codes used
• CPT/HCPCS codes submitted must describe the service performed
• Applicable diagnostic tests and evidence of other indications must also be provided (for example: laboratory tests, pathology reports, physician referrals, X-rays, and MRIs, among others)
For detailed information on codes and billing for services, see our LCA A57765 Major joint replacement (hip and knee) external link.
The code describing TKA procedures was removed by CMS from Medicare’s Inpatient-Only List (IPO) effective January 2018. This allows TKA procedures to be performed on an inpatient or outpatient basis. In other words, it allows Medicare payment to be made to the hospital for TKA procedures regardless of whether a beneficiary is admitted to the hospital as an inpatient or as an outpatient, assuming all other criteria are met.
Information about the Recovery Audit Contractor's medical review can be found in Cotiviti external link. Cotiviti is the recovery auditor for region 3, which includes Florida, Puerto Rico, and the U.S. Virgin Islands. Cotiviti may be reached at 1-866-360-2507. Claims that do not meet the coverage and documentation requirements may be denied/recovered.
Source: Local Coverage Determination (LCD) L33618 Major joint replacement (hip and knee)
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