Total Knee Arthroplasty - AK, ID, OR, WA Service Specific Post-Payment Final Findings - JF Part A
Total Knee Arthroplasty - AK, ID, OR, WA Service Specific Post-Payment Final Findings
CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Noridian's priority is to minimize potential future losses to the Medicare Trust Fund by preventing inappropriate Medicare payments. This is accomplished through provider education, training, and the medical review of claims. A post-payment review has been initiated based on data analysis .
This is to update providers of the claim review findings and closure of the file of Current Procedural Terminology (CPT®) code 27447 for AK, ID, OR, WA.
Summary of Findings
Since the initiation of the review, 200 claims were reviewed from May 24, 2021 through November 10, 2021 with an overall claim error rate of 22.0% and payment error rate of 21.8%. The breakdown of those findings are as follows:
- 156 claims were accepted
- 44 claims were denied in full for the following reasons:
- Documentation did not support medical necessity per LCD coverage requirements.
- No documentation was received in response to ADR.
If you are a provider that had claims involved in the review sample and disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice.
Education
| Paragraph Name | Paragraph Details |
|---|---|
| Medical Necessity of Total Knee Arthroplasty | Under Title XVIII of the Social Security Act, §1862 (a)(1)(A), documentation must support reasonable medical necessity of services billed. Total knee arthroplasty (TKA) may be considered reasonable and necessary if documentation supports required criteria per the Local Coverage Determination (LCD) L36577 (JF). LCD L36577 supports total knee arthroplasties may be considered medically necessary if the following criteria are met:
Please note, Local Coverage Article: Billing and Coding: Total Knee Arthroplasty A57686 (JF) for documentation requirements and approved ICD-10-CM codes for medical necessity. |
| Timely Submission of Documentation and 569PPs | It is the responsibility of Medicare providers to submit all documentation requested on the additional documentation requests (ADR) within the allotted time frame. Noridian allows 45 calendar days for the medical records to be received per the ADR request for post-payment reviews. On day 46, if the medical records have not been received, the claim will be denied provider liable with reason code 569PP. If there is no documentation to complete the medical review (MR), services billed on the claim cannot be supported. A redetermination request should be submitted to Noridian within 120 days from the date of the 569PP denial. Contractors shall reopen the claim for review as long as all conditions are met. The determination made on the reopening claim has the potential to reverse non-covered dollars. For additional information, 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 sections 1815(a), 1833(e) and 1862(a)(1)(A). |
| Anatomical Modifiers | A modifier is a two-position alpha or numeric code that is added to the end of a code to clarify the services billed. Modifiers provide a means by which the description of a service can be altered without changing the procedure code. They add more information, such as the anatomical site, to the Current Procedural Terminology (CPT®) code. In addition, they help to eliminate the appearance of duplicate billing and unbundling. Anatomic modifiers should be used on claims when the services are performed on one side to identify paired organs; such as eyes, kidneys, and lungs. The appropriate modifiers are LT for the left side of the body and RT for the right side of the body. Modifier 50 is used for bilateral procedures performed on both sides during the same operative session and billed on a single line with 1 unit. Modifiers LT and RT should not be used when modifier 50 is applicable and is restricted to operative procedures only. Modifier 50 cannot be used for procedures with code descriptor definitions of "bilateral" and "bilateral or unilateral". For additional information, reference Internet Only Manual (IOM), Publication 100-04, Medicare claims Processing Manual (MCPM), Chapter 4, Section 20.6.2 and 20.6.3. |
| Documentation Supporting Services Rendered | Under section 1833(e), Title XVIII of the Social Security Act (SSA) states, "no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period." No Medicare payment can be paid for claims that lack the necessary information for processing. Medicare claims will be allowed to process, when there is sufficient documentation in the patient's records to verify the services were performed and were medically necessary and reasonable for the medical condition. Justification for the service may be documented in the physician's clinic or hospital progress notes and/or laboratory results. If there is no documentation, or insufficient documentation to support the service, then Medicare considers the service was not rendered. Services will be denied without the necessary documentation to support services were rendered as billed. |
| Documentation to Support Medical Necessity | The practitioner that orders a service must maintain documentation to support medical necessity for that service in the beneficiary's medical record. It is the responsibility of the provider submitting the claim to maintain documentation that is received and that it reflects the information received from the ordering practitioner. The submitting provider may request additional information from the ordering practitioner to support the service billed is reasonable and necessary as laid out in the Social Security Act 1862. Upon receipt of the Additional Development Request (ADR), the billing provider must submit documentation of an order for the service, which includes information to identify and contact the ordering practitioner, to verify appropriate completion of the order and services billed. For additional information on record keeping supporting medical necessity of billed claims, refer to 42 Code of Federal Registry (CFR) section 410.32. |
View references used in review. Further educational opportunities may be found under Education and Outreach. If you are in need of an individualized education training event, contact the POE Department at mac@noridian.com. If you need coding assistance, please check your CPT®, HCPCS, ICD-10 books and your specific association.
Provider Action Required
File results and trending errors are being shared with all providers to assess compliance and billing practices if the service is provided within your facility. If your facility had claim documentation requested for this review, please refer to the individual result letter you received. You can also access individual determinations for claims that were requested from your facility by reviewing comments in either DDE or on the Noridian Medicare Portal (NMP).
Further provider action recommended includes:
- Provide education regarding errors noted to applicable staff members.
- Verify documentation supports medical necessity of Current Procedural Terminology (CPT®) code 27447.
Summary
This service specific post-payment file is now closed for AK, ID, OR, WA, and Noridian will no longer request documentation for this review. Noridian will continue to monitor data analysis and perform medical review for medical necessity and appropriate coding practices.
If you have any other questions, contact the JF Provider Contact Center at 1-877-908-8431.
