Total Knee Arthroplasty Documentation Requirements - JE Part A
Total Knee Arthroplasty Documentation Requirements
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
- Signature logs and Signature Attestation Statement [PDF] should be submitted when physician and/or clinician signatures are illegible
- If an electronic health record is used, the Electronic Order Signature Process Form [PDF] should be submitted to verify provider's Electronic Ordering System is secure
- History and physical, office visit notes, emergency room records, progress notes, nurse notes, treatment records, consultation reports and all other pertinent medical records
- Pain that interferes with activities of daily living (ADLs)
- Pain that is increased with initiation of activities
- Pain that increases with weight bearing
- 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 knee, as appropriate
- 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) the imaging was completed, type(s) of imaging/exam and detailed findings
- Physical, Occupation and Speech therapy notes, if applicable
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.
Documentation Submission
Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.
- Noridian Medical Review - Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the Acute Inpatient Prospective Payment System (PPS) Hospital webpage for additional information and resources.
Documentation Requirements Disclaimer
The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.
The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.
Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.
The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.
