Description
Documentation will be reviewed to determine if total knee arthroplasty meets Medicare coverage requirements
Affected Code(s)
CPT Codes- 27445, 27446 (CGS only), 27447, 27486, 27487
PCS Codes (FCSO ONLY) - 0SPC0JZ, 0SPD0JZ, 0SRC069, 0SRC06A, 0SRC06Z, 0SRC07Z, 0SRC0EZ, 0SRC0J9, 0SRC0JA, 0SRC0JZ, 0SRC0M9, 0SRC0MA, 0SRC0MZ, 0SRC0N9, 0SRC0NA, 0SRC0NZ, 0SRD0EZ, 0SRD0M9, 0SRD0MA, 0SRD0MZ, 0SRD0N9, 0SRD0NA, 0SRD0NZ, 0SRC0KZ, 0SRD069, 0SRD06A, 0SRD06Z, 0SRD07Z, 0SRD0J9, 0SRD0JA, 0SRD0JZ, 0SRD0KZ, 0SRT07Z, 0SRT0J9, 0SRT0JA, 0SRT0JZ, 0SRT0KZ, 0SRU07Z, 0SRU0J9, 0SRU0JA, 0SRU0JZ, 0SRU0KZ, 0SRV07Z, 0SRV0J9, 0SRV0JA, 0SRV0JZ, 0SRV0KZ, 0SRW07Z, 0SRW0J9, 0SRW0JA, 0SRW0JZ, 0SRW0KZ, 0SWC0JZ, 0SWD0JZ
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. CGS Administrators LLC, LCD L40232-Total Joint Arthroplasty; Effective 03/15/2026
9. CGS Administrators LLC, LCA A60250-Billing and Coding: Total Joint Arthroplasty; Effective 03/15/2026
10. First Coast Service Options, Inc., LCD L33618- Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 01/8/2019
11. First Coast Service Options, Inc., LCA A57765- Billing and Coding: Major Joint Replacement (Hip and Knee); Effective 10/03/2018; Revised 01/01/2026
12. Novitas Solutions, Inc., LCD L36007- Lower Extremity Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 11/14/2019
13. Novitas Solutions, Inc., LCA A56796- Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee); Effective 08/08/2019; Revised 01/01/2026
14. National Government Services, Inc., LCD L36039-Total Joint Arthroplasty; Effective 12/01/2015; Revised 10/10/2019
15. National Government Services, Inc., LCA A57428- Billing and Coding: Total Joint Arthroplasty; Effective 10/10/2019; Revised 01/01/2026
16. Palmetto GBA, LCD L33456-Total Joint Arthroplasty; Effective 10/01/2015; Revised 6/15/2023
17. Palmetto GBA, LCA A56777- Billing and Coding: Total Joint Arthroplasty; Effective 8/01/2019; Revised 01/01/2026
18. Noridian Healthcare Solutions, LLC, LCD L36575- Total Knee Arthroplasty; Effective 9/7/2016; Revised 11/06/2025
19. Noridian Healthcare Solutions, LLC, LCA A57685- Billing and Coding: Total Knee Arthroplasty; Effective 01/01/2026
20. Noridian Healthcare Solutions, LLC, LCD L36577- Total Knee Arthroplasty; Effective 9/7/2016; Revised 12/01/2019; Retired 11/06/2025
21. Noridian Healthcare Solutions, LLC, LCA A57686- Billing and Coding: Total Knee Arthroplasty; Effective 12/01/2019 ; Retired 11/06/2025
22. Wisconsin Physicians Service (WPS) Insurance Corporation, LCD L39911: Total Joint Arthroplasty; Effective 10/13/2024; Revised 02/28/2025
23. Wisconsin Physicians Service (WPS) Insurance Corporation, LCA A59811: Billing and Coding: Total Joint Arthroplasty; Effective 10/13/2024; Revised 01/01/2026
24. AMA CPT Codebook
25. AHA ICD-10-PCS Procedure Codebook