Description
Documentation will be reviewed to determine if total hip arthroplasty meets Medicare coverage requirements.
Affected Code(s)
27130, 27132, 27134, 27137, 27138 (FCSO, NGS, Novitas, Palmetto, Noridian, WPS)
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. Social Security Act (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. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 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
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. First Coast Service Options, Inc., LCD L33618- Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 01/8/2019
9. First Coast Service Options, Inc., LCA A57765- Billing and Coding: Major Joint Replacement (Hip and Knee); Effective 10/03/2018; Revised 04/11/2024
10. Novitas Solutions, Inc., LCD L36007- Lower Extremity Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 11/14/2019
11. Novitas Solutions, Inc., LCA A56796- Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee); Effective 8/8/2019; Revised 5/02/2022
12. National Government Services, Inc., LCD L36039-Total Joint Arthroplasty; Effective 12/01/2015; Revised 10/10/2019
13. National Government Services, Inc., LCA A57428- Billing and Coding: Total Joint Arthroplasty; Effective 10/10/2019; Revised 11/30/2023
14. Palmetto GBA, LCD L33456-Total Joint Arthroplasty; Effective 10/01/2015; Revised 6/15/2023
15. Palmetto GBA, LCA A56777- Billing and Coding: Total Joint Arthroplasty; Effective 8/01/2019; Revised 4/01/2024
16. Noridian Healthcare Solutions, LLC, LCD L34163- Total Hip Arthroplasty; Effective 10/01/2015; Revised 12/01/2019
17. Noridian Healthcare Solutions, LLC, LCD L36573- Total Hip Arthroplasty; Effective 9/7/2016; Revised 12/01/2019
18. Noridian Healthcare Solutions, LLC, LCA A57683- Billing and Coding: Total Hip Arthroplasty; Effective 12/01/2019
19. Noridian Healthcare Solutions, LLC, LCA A57684- Billing and Coding: Total Hip Arthroplasty; Effective 12/01/2019
20. Wisconsin Physicians Service Insurance Corp., LCD L39911 - Total Joint Arthroplasty; Effective 10/13/2024; Revised 02/28/2025Wisconsin Physicians Service Insurance Corp., LCA A59811 - Billing and Coding: Total Joint Arthroplasty; Effective 10/13/2024
21. AMA CPT Codebook
22. ICD-10-PCS Procedure Codebook