Recent Medicare auditing projects have demonstrated very high error rates among claims paid for major joint replacement surgery. On September 17, 2012, CMS published an article “as an educational guide to improve compliance with documentation requirements for major joint replacement surgery.” See Documenting Medical Necessity for Major Joint Replacement (Hip and Knee), CMS MLN Matters No. SE1236, September 17, 2012, (MLN Article). Below are key points from this article.
To avoid denial of claims, medical records should contain sufficient details “to support the determination that major joint replacement surgery was reasonable and necessary for the patient.” See MLN Article at 2. CMS further states that “conclusive statements should be avoided.” Id. Accordingly, the medical record must consist of a full description of the historical and clinical findings for each patient.
Examples may include:
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History |
Physical Examination
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Investigations
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Clinical Judgment
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Pain Description;
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Affect on daily activities;
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Safety issues (e.g. falls);
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Contraindications to non-surgical treatments;
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Failed non-surgical treatments.
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Deformity;
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Range of motion;
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Crepitus;
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Effusions;
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Tenderness;
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Gait description.
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Results of applicable investigations (e.g. plain radiographs).
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Reasons for deviating from a stepped-care approach.
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The hospital record for the preoperative joint replacement surgical patient should include:
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History |
Physical Examination
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Investigations
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Present illness from onset until the present;
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Current symptoms and functional limitations;
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Outcomes of nonsurgical treatments (medications, injections, physical therapy, assistive devices);
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Comorbidities.
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Joint examination with detailed objective findings.
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Preoperative imaging studies.
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The chart should also include documentation of specific conditions such as osteoarthritis (include severity); inflammatory arthritis (include type); failure of previous osteotomy; and any specific malignancies.
The hospital record for the postoperative joint replacement surgical patient should include operative report for the procedure, including observed pathology; daily progress notes for inpatients; and discharge plan and discharge orders.
Reporter, Katy Lucas, Atlanta, +1 404 572 2822, klucas@kslaw.com.
