Description
For purposes of coverage under Medicare, Total Hip Arthroplasty (THA), also referred to as joint replacement, have proven to be an important medical advancement. Hip Arthroplasty surgery is most commonly performed for diseases which affect the function of the hip joint (ball (femoral head). Occasionally, there may be a need to redo a THA, often referred to as a revision total hip. In revisional surgery it is important to provide replacement of the components of the previous surgery responsible for the failure. The goal of a total hip replacement surgery is to relieve pain and improve or increase functional activity of the beneficiary. This review only focuses on total (involving the entire joint) hip arthroplasties. The documentation will be reviewed to determine if a THA is medically necessary according to the guidelines outlined in the LCDs and LCAs of FCSO, Novitas, NGS, Palmetto GBA, and Noridian.
Affected Code(s)
CPT Codes- 27130, 27132, 27134, 27137, 27138 (FCSO, NGS, Novitas, Palmetto, Noridian)
PCS Codes (FCSO ONLY) - 0SP90JZ, 0SPB0JZ, 0SR9019, 0SR901A, 0SR901Z, 0SR9029, 0SR902A, 0SR902Z, 0SR9039, 0SR903A, 0SR903Z, 0SR9049, 0SR904A, 0SR904Z, 0SR9069, 0SR906A, 0SR906Z, 0SR907Z, 0SR90EZ, 0SR90J9, 0SR90JA, 0SR90JZ, 0SR90KZ, 0SRB019, 0SRB01A,0SRB01Z, 0SRB029, 0SRB02A, 0SRB02Z, 0SRB039, 0SRB03A, 0SRB03Z, 0SRB049, 0SRB04A, 0SRB04Z, 0SRB069, 0SRB06A, 0SRB06Z, 0SRB07Z, 0SRB0EZ, 0SRB0J9, 0SRB0JA, 0SRB0JZ, 0SRB0KZ, 0SW90JZ, 0SWB0JZ
Applicable Policy References
1. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
4. 42 CFR §482.24 - Condition of participation: Medical record services
5. 42 CFR §405.986- Good Cause for Reopening
6. 42 CFR §405.929- Post-Payment Review
7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
8. Medicare Benefit Policy Manual, Chapter 16- General Exclusion from Coverage, §10- General Exclusions from Coverage, §20- Services Not Reasonable and Necessary
9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §40- Surgeons and Global Surgery
10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, § §3.1-3.6.6
11. Medicare Program Integrity Manual, Chapter 13- Local Coverage Determinations, §13.5.4- Reasonable and Necessary Provisions in LCDs
12. Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services, §6.5.2-Conducting Patient Status Reviews of Claims for Medicare Part A Payment for Inpatient Hospital Admissions
13. First Coast LCD L33618- Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 01/08/2019
14. First Coast LCA A57765- Billing and Coding: Major Joint Replacement (Hip and Knee); Effective 10/03/2018; Revised 01/01/21.
15. First Coast LCA A55899- Major joint replacement (hip and knee) revision to the Part A and Part B LCD; Effective 02/15/2018, Retired 07/30/2021
16. First Coast LCA A57986- Major joint replacement (hip and knee) revision to the Part A and Part B Billing and Coding Article; Effective 02/18/2020, Retired 07/30/2021
17. Novitas LCD L36007- Lower Extremity Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 11/14/2019
18. Novitas LCA A56796- Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee); Effective 08/08/2019 Revised 05/02/22
19. NGS LCD L36039-Total Joint Arthroplasty; Effective 12/01/2015; Revised 10/10/2019
20. NGS LCA A57428- Billing and Coding: Total Joint Arthroplasty; Effective 10/10/2019
21. Palmetto LCD L33456-Total Joint Arthroplasty; Effective 10/01/2015; Revised 07/15/2021
22. Palmetto LCA A56777- Billing and Coding: Total Joint Arthroplasty; Effective 08/01/2019; Revised 10/17/2019
23. Noridian LCD L36573- Total Hip Arthroplasty; Effective 09/07/2016; Revised 12/01/2019
24. Noridian LCA A57684- Billing and Coding: Total Hip Arthroplasty; Effective 12/01/2019
25. Noridian LCD L34163- Total Hip Arthroplasty; Effective 10/01/2015; Revised 12/01/2019
26. Noridian LCA A57683- Billing and Coding: Total Hip Arthroplasty; Effective 12/01/2019
27. Annual American Medical Association CPT Manual
28. ICD-10-PCS Manual