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Checklist: Major hip and knee joint replacement or reattachment of lower extremity

This checklist is being provided as a tool to assist providers when responding to medical record documentation requests for major hip and knee joint replacement or reattachment of lower extremity (DRG 469 and 470) services.

It is the responsibility of the practitioner who provided the services to ensure the correct submission of documentation. 

Check Documentation description
  Signed, timed, and dated physician orders for each day of care/service.
  History and physical.
  Legible physician progress notes.
  All diagnostic and laboratory reports, as applicable.
  Surgical procedure reports.
  Anesthesia reports.
  Medication administration record.
  Nurses' notes.
  Discharge summary.
  Signed advanced beneficiary notice of noncoverage (ABN).
  Signed health insurance notice of non-coverage (HINN).
  Any other clinical records that support the medical necessity of the service billed.
  Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the letter.
  Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided. (History and physical, office visit notes, emergency room records, operative report, progress notes, nurse notes, Medication Administration Record (MAR), treatment records, consultation reports, discharge summary, and all other pertinent medical records.
  Documentation supporting pain history and functional disability from injury due to trauma or arthritis of the joint. Examples include but are not limited to: Pain that interferes with Activities of Daily Living (ADLs), Pain that is increased with initiation of activities, or Pain that increases with weight bearing, or pain precluding sleep.
 

Documentation supporting unsuccessful and reasonable attempt at conservative therapy (non-surgical medical management) (typically 3 months or more), if appropriate. Examples include, but are not limited to:

  • Trial of Nonsteroidal Anti-inflammatories (NSAIDs) or analgesics, supervised physical therapy or documented contraindication to physical therapy, Flexibility and muscle strengthening exercises, Assistive device use, Weight reduction, as appropriate, Therapeutic injections into the hip, as appropriate
  • A statement of "failed conservative/outpatient treatment" is not sufficient
  Documentation should support that ADLs are diminished due to pain or disability despite non-surgical medical management.
 

Arthritis of the knee or hip supported by X-ray or MRI. The X-ray or MRI must demonstrate one of the following:

  • Subchondral cysts
  • Subchondral sclerosis
  • Periarticular osteophytes
  • Joint subluxation
  • Degree of joint space narrowing
  • Avascular necrosis
  • Bone on bone articulations
  • When no official imaging report is available, the following components must be present within medical records: date(s) imaging was completed, type(s) of imaging/exam and detailed findings
  Rehabilitation records: Physical, Occupation and Speech therapy notes, if applicable.
  For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKA or THA should be appropriately addressed in the medical record.

 

Disclaimer 
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.