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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:

Check Brief Description
 

Legible handwritten physician and/or clinician signatures
 

Valid electronic physician and/or clinician signatures
  Physician or Non-Physician Practitioner (NPP) order for the date of service (including admission order, if applicable)
  Physician certification of medical necessity of admission, if applicable
  Legible procedure note or report that includes sufficient detail to allow reconstruction of the procedure
 

Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided

  • History and physical, office visit notes, emergency room records, progress notes, nurse notes, treatment records, consultation reports and all other pertinent medical records
 

Documentation supporting pain history and functional disability from injury due to trauma or arthritis of joint. Examples include, but are not limited to:

  • Pain that interferes with activities of daily living (ADLs)
  • Pain that is increased with initiation of activities
  • Pain that increases with weight bearing
 

Documentation supporting unsuccessful and reasonable attempt at conservative therapy (non-surgical medical management), if appropriate. Examples include, but are not limited to:

  • 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

A statement of "failed conservative/outpatient treatment" is not sufficient
 

Pre-procedure radiographic supported evidence or when conventional radiography is not adequate magnetic resonance imaging (MRI) supported evidence showing one or more of the following:

  • 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
  Medication Administration Record (MAR)
  Observation orders and daily progress notes, if applicable
 

Rehabilitation records:

  • Physical, Occupation and Speech therapy notes, if applicable
  Disposition/discharge notes/hospital discharge summary
  Full detailed itemized bill indicating revenue code
  Coding query form, if applicable
  Quality Improvement Organization (QIO) letter, if applicable
  Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable
  Advance Beneficiary Notice of Noncoverage (ABN), 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.

View the Acute Inpatient Prospective Payment System (PPS) Hospital webpage for additional information and resources.

 

Last Updated Fri, 28 Oct 2022 16:20:56 +0000

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.