Total Knee Arthroplasty - AZ, UT, MT, ND, SD, WY Service Specific Post-Payment Final Findings - JF Part A
Total Knee Arthroplasty - AZ, UT, MT, ND, SD, WY 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 AZ, UT, MT, ND, SD, and WY.
Summary of Findings
Since the initiation of the review, 200 claims were reviewed from May 31, 2021 through November 16, 2021 with an overall claim error rate of 36% and payment error rate of 36.8%. The breakdown of those findings are as follows:
- 128 claims were accepted.
- 72 claims were denied in full for the following reasons:
- Documentation was not received timely in response to the additional documentation request (ADR).
- Documentation did not support medical necessity per LCD requirements.
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.
|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 (JF) supports total knee arthroplasties may be considered medically necessary if the following criteria are met:
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 188.8.131.52, 42 CFR 424.5(a)(6), and Social Security Act sections 1815(a), 1833(e) and 1862(a)(1)(A).
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 email@example.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.
This service specific post-payment file is now closed for JF 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.
Last Updated Fri, 03 Dec 2021 14:28:40 +0000