Major Joint Replacement for Hip and Knee – Documenting Medical Necessity

Findings by the Comprehensive Error Rate Testing (CERT) post review contractor have identified common errors related to billing major joint replacement (hip and knee) surgery for Medicare beneficiaries.

CMS has published Medicare Learning Network (MLN) Matters (MM) Special Edition (SE)1236 This link takes you to an external website. regarding this topic. Providers are encouraged to review this information as an educational guide to improve compliance with documentation requirements for major joint replacement surgery.

Examples of current CERT denials are based on (not an all inclusive list):

  • Lack of historical information and conservative treatments documented
  • Lack of detailed information to support the surgery was reasonable/necessary (see MLN for descriptions)

Conservative treatment and historical information may be located in the referring physician's office or clinic records. The referring physician's office or clinic should be contacted for the documents to support the necessity of the service.

If you have received a CERT related denial for either of these procedure types listed above and believe you have additional documentation, email Noridian at CERTQuestion@noridian.com with the Claim IDentification (CID) #, your contact person's name and phone number.

Last Updated Sep 05, 2014