Medicare Compliance & Reimbursement

One obstacle to foolproof documentation for total joint replacement is the lack of a national coverage determination. Instead, providers have to make the most of a patchwork quilt of local coverage determinations and nonbinding guidance. Still, the more knowledge the better, advises Steven J. Meyerson, MD, vice president with Accretive Physician Advisory Services in Chicago. He reminds providers that even “foreign” LCDs (issued by contractors outside of your region) can provide sound guidance. 

• In January 2013, Cahaba GBA released its LCD, Surgery: Major Joint Replacement (Hip and Knee) (L32971). This new LCD describes coverage of total hip and total knee replacement surgery and redo/revision of hip and knee replacement, says Cahaba. The CPT® codes noted are: (hip) 27130, 27132, 27134, 27137, 27138 and (knee) 27445, 27447, 27486, 27487, but the LCD is rich in its guidance on medical necessity, says Debbie Rubio, BS, MT (ASCP), manager of regulatory affairs and compliance at Medical Management Plus, Inc., in Birmingham, Al.
• First Coast’s related LCD L32081 and L32078 are also available at CMS’s Medicare Coverage Determination Database web site at www.cms.gov/medicare-coverage-database/search/advanced-search.aspx.
• The MLN Matters article on joint replacement coverage (SE1236, Documenting Medical Necessity for Major Joint Replacement, Hip and Knee) is available at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2012-Transmittals-Items/SE1236.html.