The Jurisdiction E, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of for Current Procedural Terminology (CPT®) code 27447 - Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty). The quarterly edit effectiveness results from April 1, 2023 through June 30, 2023 are as follows:

Top Denial Reasons

• Medical Necessity of Total Knee Arthroplasty

Educational Resources

• Documentation Requirements
• Local Coverage Determination (LCD): Total Knee Arthroplasty (L36575)
• Local Coverage Article (LCA): Billing and Coding: Total Knee Arthroplasty (A57686)
• IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3
• IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6

Education

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.

The following criteria support total knee arthroplasty medical necessity per the Total Knee Arthroplasty LCD L36575:

• Advanced joint disease demonstrated by imaging support of:
• Subchondral cysts
• Subchondral sclerosis
• Periarticular osteophytes
• Joint subluxation
• Joint space narrowing
• Avascular necrosis
• Bone on bone; and
• Pain or functional disability; and
• Conservative measures trialed and failed, if appropriate

Examples: anti-inflammatories or analgesics, flexibility and muscle strengthening exercises, physical therapy, assistive device use, weight reduction or therapeutic injections.

Refer to Total Knee Arthroplasty LCD L36575 for documentation requirements and coverage and limitations. Local Coverage Article Billing and Coding: Total Knee Arthroplasty A57685 details documentation requirements and approved ICD-10-CM codes.