Local Coverage Determination (LCD)

Total Joint Arthroplasty

L33456

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Contractor Information

LCD Information

Document Information

LCD ID
L33456
LCD Title
Total Joint Arthroplasty
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 07/15/2021
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
04/23/2015
Notice Period End Date
06/07/2015
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

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Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

21 CFR, Chapter 1, Subchapter H, Part 888, §888.1100 Orthopedic Devices-Arthroscope

42 CFR §482.24- Condition of participation: Medical record services

CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 6, §6.5.2, Conducting Patient Status Reviews of Claims for Medicare Part A Payment for Inpatient Hospital Admissions.

CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, §3.4.1.3 Diagnosis Code Requirements

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Joint replacement surgery has been performed on millions of people over the past several decades and has proved to be an important medical advancement in the field of orthopedic surgery. The hip and knee are the two most commonly replaced joints. The knee is the largest joint in the body and includes the lower end of the femur, the upper end of the tibia and the patella. The knee joint has three compartments, the medial, the lateral and the patellofemoral. The surfaces of these compartments are covered with articular cartilage and are bathed in synovial fluid. The bones of the knee joint work together, allowing the knee to function smoothly. The hip is a large weight bearing joint made up of two components: a ball (femoral head) and socket (acetabulum). These components are covered with articular cartilage and are bathed in synovial fluid produced by a synovial membrane.

The most common reason for total knee replacement (TKR) surgery is arthritis of the knee joint. Types of arthritis include:

  • osteoarthritis,
  • rheumatoid arthritis and
  • traumatic arthritis (arthritis which occurs as a result of injury).

Arthritis causes a severe limitation in the activities of daily living (ADLs), including difficulty with walking, squatting, and climbing stairs. Pain is typically most severe with activity and patients often have difficulty getting mobilized when seated for a long time. Other findings include chronic knee inflammation or swelling not relieved by rest, knee stiffness, lack of pain relief after taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement with other conservative therapies such as steroid injections and physical therapy.

Osteonecrosis and malignancy are additional reasons to proceed with TKR Surgery. The use of TKR in patients with malignancy must be weighed against considerations of life expectancy and possible alternative procedures to relieve pain. The goal of TKR is to relieve pain and improve or increase patient function.

Total hip replacement (THR) surgery is most often performed due to severe pain caused by osteoarthritis of the hip joint. Rheumatoid arthritis, traumatic arthritis, malignancy involving the hip joint and osteonecrosis of the femoral head are also causes for hip replacement surgery. The use of THR in patients with malignancy must be weighed against considerations of life expectancy and possible alternative procedures to relieve pain. The pain from the damaged joint usually limits ADLs, such as walking, bathing and cooking. The pain can also cause disruption of sleep due to the inability to lie on the hip while in bed. Pain relief not achieved by taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement with other conservative therapies such as physical therapy, activity modification and (in some patients) assistive device use are reasons for proceeding with a THR. The goal of THR surgery is to relieve pain and improve or increase patient function.

Occasionally, there may be a need to perform a reoperation on a previous THR or TKR. This is often referred to as a revision total knee or revision total hip. Circumstances that lead to the need for a revision total hip or knee are continued disabling pain and/or continued decline in function which can be attributed to failure of the primary joint replacement. Failure can be due to infection involving the joint, substantial bone loss in the structures supporting the prosthesis, fracture, aseptic loosening of the components and wear of the prosthetic components.

Total Knee Arthroplasty (TKA)

Indications:

Palmetto GBA will consider TKR surgery medically necessary when one or more of the following criteria are met:

Advanced joint disease demonstrated by:

  • Radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis); 

  • Pain or functional disability from injury due to trauma or arthritis of the joint; and

  • If appropriate, a history of unsuccessful conservative therapy (non-surgical medical management) that is clearly addressed in the pre procedure medical record. (If conservative therapy is not appropriate, the medical record must clearly document why such approach is not reasonable) 

  • Failure of a previous osteotomy; 

  • Distal femur fracture; 

  • Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; 

  • Failure of previous unicompartmental knee replacement; 

  • Avascular necrosis of the knee; or

  • Proximal tibia fracture

Non-surgical medical management is usually, but not always, implemented prior to scheduling total joint surgery. Non-surgical treatment as clinically appropriate for the patient’s current episode of care typically includes one or more of the following:

  • anti-inflammatory medications, analgesics, 

  • flexibility and muscle strengthening exercises, 

  • supervised physical therapy [ADLs diminished despite completing a plan of care], 

  • assistive device use, 

  • weight reduction as appropriate, or

  • therapeutic injections into the knee as appropriate.

In some circumstances, for example, if the patient has bone on bone articulation, severe deformity, or pain and significant disabling interference with ADLs, the surgeon may determine that nonsurgical medical management would be ineffective or counterproductive, and that the best treatment option, after explaining the risks, is surgical. If medical management is deemed inappropriate, the medical record should indicate the rationale for and circumstances under which this is the case.

Indications for Replacement/Revision of TKA

  • Loosening of one or more components, 

  • Fracture or mechanical failure of one or more components, 

  • Infection, 

  • Treatment of periprosthetic fracture of distal femur, proximal tibia or patella, 

  • Progressive or substantial periprosthetic bone loss, 

  • Bearing surface wear leading to symptomatic synovitis, 

  • Implant or knee misalignment, 

  • Knee stiffness/arthrofibrosis, 

  • Tibiofemoral instability, or

  • Extensor mechanism instability

Total Hip Arthroplasty (THA)

Indications:

Palmetto GBA will consider THR surgery medically necessary when one or more of the following criteria are met:

Advanced joint disease demonstrated by:

  • Radiographic supported evidence or when conventional radiography is not adequate, MRI supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis); 

  • Pain that cannot be adequately controlled despite optimal conservation treatment or functional disability from injury due to trauma or arthritis of the joint); and

  • If appropriate, a history of unsuccessful conservative therapy (non-surgical medical management) that is clearly addressed in the pre procedure medical record. (If conservative therapy is not appropriate, the medical record must clearly document the rationale for why such approach is not reasonable)

  • Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; 

  • Avascular necrosis (osteonecrosis of femoral head); 

  • Fracture of the femoral neck; 

  • Acetabular fracture; 

  • Nonunion or failure of previous hip fracture surgery; or

  • Malunion of acetabular or proximal femur fracture

Non-surgical medical management is usually, but not always, implemented prior to scheduling total joint surgery. Non-surgical treatment as clinically appropriate for the patient’s current episode of care typically includes one or more of the following:

  • anti-inflammatory medications or analgesics, 

  • flexibility and muscle strengthening exercises, 

  • supervised physical therapy [ADLs diminished despite completing a plan of care], 

  • assistive device use, 

  • weight reduction as appropriate, or

  • therapeutic injections into the hip as appropriate.

Indications for Replacement/Revision of THA

  • Loosening of one or both components; 

  • Fracture or mechanical failure of the implant; 

  • Recurrent or irreducible dislocation; 

  • Infection; 

  • Treatment of a displaced periprosthetic fracture; 

  • Clinically significant leg length inequality not amenable to conservative management; 

  • Progressive or substantial bone loss; 

  • Bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction; 

  • Clinically significant audible noise; or

  • Adverse local tissue reaction.

Limitations:

Palmetto GBA will not consider a TKR or THR medically necessary when the following contraindications are present:

  • Active infection of the hip or knee joint or active systemic bacteremia

  • Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned surgical site of the hip or knee

  • Rapidly progressive neurological disease except in the clinical situation of a concomitant displaced femoral neck fracture

The following conditions are relative contraindications to TKR or THR and if such surgery is performed in the presence of these conditions, it is expected that the rationale for proceeding with the surgery under such circumstances is clearly documented in the medical record:

  • Absence or relative insufficiency of abductor musculature

  • Any process that is rapidly destroying bone

  • Neurotrophic arthritis

This local coverage determination (LCD) is only addressing medical necessity criteria for performing THR and TKR surgery. With respect to knee replacement surgery, there is a form of knee joint replacement surgery called unicompartmental knee replacement. This is typically done for patients with osteoarthritis of the knee in which the damage is contained to one compartment of the knee. The indications outlined in this LCD are not to be applied for unicompartmental knee replacement surgery. Failed previous unicompartmental joint replacement is an indication for performing a TKA.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

Documentation Requirements

In order to qualify for coverage of both Medicare Part A inpatient services and Part B provider services, the medical record must contain documentation that fully supports the medical necessity and justification of the procedure performed and must be made available to Palmetto GBA upon request. When the documentation does not meet the criteria for the service(s) rendered or the documentation does not establish the medical necessity for the service(s), such service(s) will be denied as not reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act.

A history and physical, discharge summary, physician progress notes and an operative report are typically in the hospital record for the procedures in this LCD. Other relevant information addressing coverage criteria related to the patient’s episode of care prior to the hospitalization, should be included in the hospital record (see below). Failure to include this information in the hospital record may result in denial of coverage for Part A services and trigger a review of the Part B provider claim to determine whether the Part B service rendered was reasonable and necessary.

When the procedure is indicated for advanced joint disease, the following should be documented in the medical record:

    • Arthritis of the knee or hip supported by X-ray or MRI. The X-ray or MRI should demonstrate one of the following:
      • subchondral cysts,
      • subchondral sclerosis,
      • periarticular osteophytes,
      • joint subluxation,
      • joint space narrowing,
      • avascular necrosis or
      • bone on bone articulation
  • Pain or functional disability at the hip or knee. For example, documented pain that interferes with ADLs (functional disability), or pain that is increased with initiation of activities or pain that increases with weight bearing.

  • Unsuccessful conservative therapy (non-surgical medical management) if appropriate. The documentation should demonstrate a history of a reasonable attempt at conservative therapy as appropriate for the patient in their current episode of care. For example, a documented trial of NSAIDs or contraindication to such therapy and/or documented supervised physical therapy. Documentation should support that ADLs are diminished due to pain and/or disability despite non-surgical medical management.

  • For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKA or THA should be appropriately addressed in the medical record.


Medical record documentation for other TKA and THA indications outlined in the LCD should include the following, when indicated:

  • Supporting evidence (e.g., pathology reports and referral from an Oncologist for a malignancy of the joint or X-ray of a fracture).

  • Pain at the hip or knee when indicated as a reason for the procedure (e.g., for revision/replacement TKA/THA). For example, documented pain that interferes with ADLs (functional disability), pain that is increased with initiation of activities or pain that increases with weight bearing.

  • For patients with significant conditions or co-morbidities, the risk/benefit of non-cardiac surgery, such as TKA or THA should be appropriately addressed in the medical record.

  • When infection is the reason for revision TKA or THA surgery, laboratory and/or pathology reports must be in the medical record and all documentation regarding treatment of the infection and a physician note indicating that it is appropriate to proceed with surgery.


In the instance that the patient is undergoing a bilateral knee or hip replacement, all criteria listed above would apply to the bilateral surgery when indicated. The medical record should also support the medical necessity for performing a bilateral THA or TKA.

The treating physician must discuss the significant benefit and risks with the patient. In order to meet Medicare’s reasonable and necessary (R&N) threshold for coverage of a procedure, the physician’s documentation for the case should clearly support both the diagnostic criteria for the indication (standard test results and/or clinical findings as applicable) and the medical need (the procedure does not exceed the medical need and is at least as beneficial as existing alternatives & the procedure is furnished with accepted standards of medical practice in a setting appropriate for the patient’s medical needs and condition). Lacking compelling arguments for an exception in the supporting documentation, the hospital (FISS claim) and physician services (MCS claim) can be denied.

If in certain circumstances the patient does not meet all of the required criteria outlined in the local coverage determination (LCD) for a procedure, but the treating physician feels that the procedure is a covered procedure given the current standards of care, then the documentation must clearly outline the patient’s episode of care that supports the major procedure and must clearly address the reason(s) for coverage. For example, if clinical findings (or lack of) for an indication are not consistent with the LCD criteria, it should be directly addressed in the pre procedure documentation. For example, if certain conservative measures are not necessary or appropriate for a given patient, it should be directly noted in the pre-procedure documentation. The clinical judgment of the treating physician is always a consideration if clearly addressed in the pre-procedure record and if consistent with the episode of care for the patient as documented in patient records and claim history.

Review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at any time during the stay. The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis.

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters they may be subject to review for medical necessity.

The devices/implants utilized for total knee and total hip replacement surgeries are regulated by the Food and Drug Administration (FDA) as medical devices. The devices used should be class II or class III devices that meet the requirements outlined in CFR 21, Chapter 1, subchapter H, Part 888.

Sources of Information
N/A
Bibliography
  1. Ackerman IN, Bennell KL, Osborne RH. Decline in health-related quality of life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study. BMC Musculoskeletal Disorders. 2011;12:108.
  2. Agency for Healthcare Research and Quality (AHRQ). Total Knee Replacement. Accessed 6/3/2021
  3. American Academy of Orthopaedic Surgeons. Total Knee Replacement. Accessed 6/3/2021
  4. Dennis DA, Berry DJ, Engh G, et al. Revision total knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2008:16(8):442-454.
  5. Emedicine. Total Knee Arthroplasty. Accessed 6/3/2021
  6. Feeley BT, Gallo RA, Sherman S, Williams RJ. Management of osteoarthritis of the knee in the active patient. Journal of the American Academy of Orthopaedic Surgeons. 2010;18(7):406-416.
  7. InterQual® 2017 Procedures Adult Criteria, Total joint replacement, knee and hip & removal and replacement, total joint replacement knee and hip. McKesson Corporation.
  8. Milliman Care Guidelines® 2017. Inpatient and surgical care 15th edition. Knee arthroplasty and hip arthroplasty. Milliman Care Guidelines LLC.
  9. O’Connor MI. Implant survival, knee function and pain relief after TKA: Are there differences between men and women? Clinical Orthopaedics & Related Research. 2011;469(7):1846-1851.
  10. Richmond J, Hunter D, Irrgang J, et al. Treatment of osteoarthritis of the knee (non-arthroplasty). J Amer Acad Orthop Surg. 2009;17(9):591-600.
  11. U.S. National Library of Medicine, National Institute of Health. Hip joint replacement. Accessed 6/3/2021

Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
07/15/2021 R19

Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting was revised and acronyms were placed throughout the LCD where needed.

  • Provider Education/Guidance
10/24/2019 R18

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Title XVIII of the Social Security Act, §1833(e) was removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Total Joint Arthroplasty A56777 article.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
08/01/2019 R17

All coding located in the Coding Information section has been moved into the related Billing and Coding: Total Joint Arthroplasty A56777 article and removed from the LCD.

Formatting was corrected throughout the LCD and reference access dates were updated under the Bibliography section.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
10/26/2018 R16

Under ICD-10 Codes that Support Medical Necessity Group: 2 Paragraph added CPT® code 27132.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Typographical Error
10/26/2018 R15

Under CPT/HCPCS Codes – Group 2: Codes added CPT® code 27132.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Reconsideration Request
05/14/2018 R14

Under CMS National Coverage Policy corrected the title for CMS Internet-Only Manual, Pub 100-08, Ch 6, Sec 6.5.2. Under Coverage Indications, Limitations and/or Medical Necessity removed verbiage “and” and “or” after multiple bullets throughout the section. In the fourth paragraph, replaced “total knee replacement” with (TKR) and moved before the word “surgery”. Replaced “total knee replacement” with TKR in the last sentence. In the fifth paragraph, replaced “activities of daily living” with ADLs in the fourth sentence. Replaced “total hip replacement” with THR in all applicable areas of the paragraph. Under Total Knee Arthroplasty (TKA) removed “activities of daily living” from the third bullet of the second paragraph. In the first sentence of the third paragraph, added the acronym ADLs and removed “activities of daily living”. Under Total Hip Arthroplasty (THA) removed “activities of daily living” in the third bullet in the second set of bullets. Under ICD-10 Codes that Support Medical Necessity added codes Z47.32 to groups 1 and 2, Z47.33 to groups 3 and 4, and Z89.621 and Z89.622 to groups 1 and 2. Under Associated Information – Documentation Requirements added a comma in the first sentence after “provider services”. Under Bibliography made changes to citations to reflect AMA citation guidelines. Changed the access date to 4/1/2018 on all URLs listed (this includes the second, fifth, tenth and eleventh source listed). Changed InterQual® procedures criteria and Milliman Care Guidelines® from 2011 to 2017. Corrected the URL link for the last citation.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
  • Reconsideration Request
02/26/2018 R13 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R12 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
04/13/2017 R11 Under Coverage Indications, Limitations and/or Medical Necessity- created sixth paragraph starting with sentence “Occasionally, there may be a need…”
Under ICD-10 Codes that Support Medical Necessity- added a space between comments under Group 2: Asterisk and the start of header Group 3: Paragraph
Under Sources of Information and Basis for Decision- corrected the title of the second reference to read, “Total Knee Replacement” and corrected the Accessed date to 3/15/17. Added “et al” to references for the fourth reference. Corrected the accessed date on fifth, tenth and eleventh reference to 3/15/17.
  • Provider Education/Guidance
  • Typographical Error
10/01/2016 R10 Under ICD-10 Codes That Support Medical Necessity: Group 1 added M84.751A, M84.751D, M84.751G, M84.751K, M84.751P, M84.751S, M84.752A, M84.752D, M84.752G, M84.752K, M84.752P, M84.752S, M84.754A, M84.754D, M84.754G, M84.754K, M84.754P, M84.754S, M84.755A, M84.755D, M84.755G, M84.755K, M84.755P, M84.755S, M84.757A, M84.757D, M84.757G, M84.757K, M84.757P, M84.757S, M84.758A, M84.758D, M84.758G, M84.758K, M84.758P, and M84.758S. Under ICD-10 Codes That Support Medical Necessity: Group 2 added M97.01XA, M97.01XD, M97.01XS, M97.02XA, M97.02XD, and M97.02XS. Under ICD-10 Codes That Support Medical Necessity: Group 2 Asterisk added M97.01XA-M97.02XS to the paragraph and deleted T84.040A-T84.041S from the paragraph. Under ICD-10 Codes That Support Medical Necessity: Group 4 added M97.11XA, M97.11XD, M97.11XS, M97.12XA, M97.12XD, and M97.12XS. Under ICD-10 Codes That Support Medical Necessity: Group 4 Asterisk added M97.11XA-M97.12XS to the paragraph. Under ICD-10 Codes That Support Medical Necessity: Group 2 deleted T84.040A, T84.040D, T84.040S, T84.041A, T84.041D, and T84.041S. Under ICD-10 Codes That Support Medical Necessity: Group 4 deleted T84.042S and T84.043S. This revision is due to the Annual ICD-10 Code Update.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
08/08/2016 R9 Under Sources of Information and Basis for Decision removed the URL for National Guideline Clearinghouse. Medical Management of Adults with Osteoarthritis.
  • Revisions Due To ICD-10-CM Code Changes
08/08/2016 R8 Under ICD-10 Codes that Support Medical Necessity Group 1 added ICD-10 codes M80.051A, M80.051G, M80.051K, M80.052A, M80.052G, M80.052K, M80.851A, M80.851G, M80.851K, M80.852A, M80.852G, M80.852K, M84.351A, M84.351G, M84.351K, M84.352A, M84.352G, M84.352K, M84.451A, M84.451G, M84.451K, M84.452A, M84.452G, M84.452K, M84.551A, M84.551G, M84.551K, M84.552A, M84.552G, M84.552K, M84.651A, M84.651G, M84.651K, M84.652A, M84.652G, M84.652K, S32.301A, S32.301G, S32.301K, S32.302A, S32.302G, S32.302K, S32.311A, S32.311G, S32.311K, S32.312A, S32.312G, S32.312K, S32.314A, S32.314G, S32.314K, S32.315A, S32.315G, S32.315K, S32.391A, S32.391G, S32.391K, S32.392A, S32.392G, S32.392K, S32.401A, S32.401G, S32.401K, S32.402A, S32.402G, S32.402K, S32.411A, S32.411G, S32.411K, S32.412A, S32.412G, S32.412K, S32.414A, S32.414G, S32.414K, S32.415A, S32.415G, S32.415K, S32.421A, S32.421G, S32.421K, S32.422A, S32.422G, S32.422K, S32.424A, S32.424G, S32.424K, S32.425A, S32.425G, S32.425K, S32.431A, S32.431G, S32.431K, S32.432A, S32.432G, S32.432K, S32.434A, S32.434G, S32.434K, S32.435A, S32.435G, S32.435K, S32.441A, S32.441G, S32.441K, S32.442A, S32.442G, S32.442K, S32.444A, S32.444G, S32.444K, S32.445A, S32.445G, S32.445K, S32.451A, S32.451G, S32.451K, S32.452A, S32.452G, S32.452K, S32.454A, S32.454G, S32.454K, S32.455A, S32.455G, S32.455K, S32.461A, S32.461G, S32.461K, S32.462A, S32.462G, S32.462K, S32.464A, S32.464G, S32.464K, S32.465A, S32.465G, S32.465K, S32.471A, S32.471G, S32.471K, S32.472A, S32.472G, S32.472K, S32.474A, S32.474G, S32.474K, S32.475A, S32.475G, S32.475K, S32.481A, S32.481G, S32.481K, S32.482A, S32.482G, S32.482K, S32.484A, S32.484G, S32.484K, S32.485A, S32.485G, S32.485K, S32.491A, S32.491G, S32.491K, S32.492A, S32.492G, S32.492K, S32.591A, S32.591G, S32.591K, S32.592A, S32.592G, S32.592K, S32.601A, S32.601G, S32.601K, S32.602A, S32.602G, S32.602K, S32.611A, S32.611G, S32.611K, S32.612A, S32.612G, S32.612K, S32.614A, S32.614G, S32.614K, S32.615A, S32.615G, S32.615K, S32.691A, S32.691G, S32.691K, S32.692A, S32.692G, S32.692K, S32.89XA, S32.89XG, S32.89XK, S72.011A, S72.011G, S72.011K, S72.012A, S72.012G, S72.012K, S72.021A, S72.021G, S72.021K, S72.022A, S72.022G, S72.022K, S72.024A, S72.024G, S72.024K, S72.025A, S72.025G, S72.025K, S72.031A, S72.031G, S72.031K, S72.032A, S72.032G, S72.032K, S72.034A, S72.034G, S72.034K, S72.035A, S72.035G, S72.035K, S72.041A, S72.041G, S72.041K, S72.042A, S72.042G, S72.042K, S72.044A, S72.044G, S72.044K, S72.045A, S72.045G, S72.045K, S72.051A, S72.051G, S72.051K, S72.052A, S72.052G, S72.052K, S72.061A, S72.061G, S72.061K, S72.062A, S72.062G, S72.062K, S72.064A, S72.064G, S72.064K, S72.065A, S72.065G, S72.065K, S72.091A, S72.091G, S72.091K, S72.092A, S72.092G, S72.092K, S72.101A, S72.101G, S72.101K, S72.102A, S72.102G, S72.102K, S72.111A, S72.111G, S72.111K, S72.112A, S72.112G, S72.112K, S72.114A, S72.114G, S72.114K, S72.115A, S72.115G, S72.115K, S72.121A, S72.121G, S72.121K, S72.122A, S72.122G, S72.122K, S72.124A, S72.124G, S72.124K, S72.125A, S72.125G, S72.125K, S72.131A, S72.131G, S72.131K, S72.132A, S72.132G, S72.132K, S72.134A, S72.134G, S72.134K, S72.135A, S72.135G, S72.135K, S72.141A, S72.141G, S72.141K, S72.142A, S72.142G, S72.142K, S72.144A, S72.144G, S72.144K, S72.145A, S72.145G, S72.145K, S72.21XA, S72.21XG, S72.21XK, S72.22XA, S72.22XG, S72.22XK, S72.24XA, S72.24XG, S72.24XK, S72.25XA, S72.25XG, S72.25XK, S72.391A, S72.391G, S72.391K, S72.392A, S72.392G, S72.392K, S72.8X1A, S72.8X1G, S72.8X1K, S72.8X2A, S72.8X2G, S72.8X2K, S79.001A, S79.001G, S79.001K, S79.002A, S79.002G, S79.002K, S79.011A, S79.011G, S79.011K, S79.012A, S79.012G, S79.012K, S79.091A, S79.091G, S79.091K, S79.092A, S79.092G, S79.092K. Under ICD-10 Codes that Support Medical Necessity Group 3 added ICD-10 codes M84.461A, M84.461G, M84.461K, M84.462A, M84.462G, M84.462K, M84.561A, M84.561G, M84.561K, M84.562A, M84.562G, M84.562K, M84.661A, M84.661G, M84.661K, M84.662A, M84.662G, M84.662K, S72.401A, S72.401G, S72.401K, S72.402A, S72.402G, S72.402K, S72.411A, S72.411G, S72.411K, S72.412A, S72.412G, S72.412K, S72.414A, S72.414G, S72.414K, S72.415A, S72.415G, S72.415K, S72.421A, S72.421G, S72.421K, S72.422A, S72.422G, S72.422K, S72.424A, S72.424G, S72.424K, S72.425A, S72.425G, S72.425K, S72.431A, S72.431G, S72.431K, S72.432A, S72.432G, S72.432K, S72.434A, S72.434G, S72.434K, S72.435A, S72.435G, S72.435K, S72.441A, S72.441G, S72.441K, S72.442A, S72.442G, S72.442K, S72.444A, S72.444G, S72.444K, S72.445A, S72.445G, S72.445K, S72.451A, S72.451G, S72.451K, S72.452A, S72.452G, S72.452K, S72.454A, S72.454G, S72.454K, S72.455A, S72.455G, S72.455K, S72.461A, S72.461G, S72.461K, S72.462A, S72.462G, S72.462K, S72.464A, S72.464G, S72.464K, S72.465A, S72.465G, S72.465K, S72.471A, S72.471G, S72.471K, S72.472A, S72.472G, S72.472K, S72.491A, S72.491G, S72.491K, S72.492A, S72.492G, S72.492K, S72.8X1A, S72.8X1G, S72.8X1K, S72.8X2A, S72.8X2G, S72.8X2K, S79.101A, S79.101G, S79.101K, S79.102A, S79.102G, S79.102K, S79.111A, S79.111G, S79.111K, S79.112A, S79.112G, S79.112K, S79.121A, S79.121G, S79.121K, S79.122A, S79.122G, S79.122K, S79.131A, S79.131G, S79.131K, S79.132A, S79.132G, S79.132K, S79.141A, S79.141G, S79.141K, S79.142A, S79.142G, S79.142K, S79.191A, S79.191G, S79.191K, S79.192A, S79.192G, S79.192K, S82.001A, S82.001G, S82.001K, S82.002A, S82.002G, S82.002K, S82.011A, S82.011G, S82.011K, S82.012A, S82.012G, S82.012K, S82.014A, S82.014G, S82.014K, S82.015A, S82.015G, S82.015K, S82.021A, S82.021G, S82.021K, S82.022A, S82.022G, S82.022K, S82.024A, S82.024G, S82.024K, S82.025A, S82.025G, S82.025K, S82.031A, S82.031G, S82.031K, S82.032A, S82.032G, S82.032K, S82.034A, S82.034G, S82.034K, S82.035A, S82.035G, S82.035K, S82.041A, S82.041G, S82.041K, S82.042A, S82.042G, S82.042K, S82.044A, S82.044G, S82.044K, S82.045A, S82.045G, S82.045K, S82.091A, S82.091G, S82.091K, S82.092A, S82.092G, S82.092K, S82.101A, S82.101G, S82.101K, S82.102A, S82.102G, S82.102K, S82.121A, S82.121G, S82.121K, S82.122A, S82.122G, S82.122K, S82.124A, S82.124G, S82.124K, S82.125A, S82.125G, S82.125K, S82.131A, S82.131G, S82.131K, S82.132A, S82.132G, S82.132K, S82.134A, S82.134G, S82.134K, S82.135A, S82.135G, S82.135K, S82.141A, S82.141G, S82.141K, S82.142A, S82.142G, S82.142K, S82.144A, S82.144G, S82.144K, S82.145A, S82.145G, S82.145K, S82.161A, S82.161G, S82.161K, S82.162A, S82.162G, S82.162K, S82.191A, S82.191G, S82.191K, S82.192A, S82.192G, S82.192K, S89.001A, S89.001G, S89.001K, S89.002A, S89.002G, S89.002K, S89.011A, S89.011G, S89.011K, S89.012A, S89.012G, S89.012K, S89.021A, S89.021G, S89.021K, S89.022A, S89.022G, S89.022K, S89.031A, S89.031G, S89.031K, S89.032A, S89.032G, S89.032K, S89.041A, S89.041G, S89.041K, S89.042A, S89.042G, S89.042K, S89.091A, S89.091G, S89.091K, S89.092A, S89.092G, S89.092K.
  • Provider Education/Guidance
  • Reconsideration Request
06/16/2016 R7 Under ICD-10 Codes that Support Medical Necessity Group 1 added ICD-10 codes M05.89, M06.09, M06.89, M08.09, M08.29, M08.89, M08.99, M80.051S, M80.052S, M80.851S, M80.852S, M84.351S, M84.352S, M84.451S, M84.452S, M84.551S, M84.552S, M84.651S, M84.652S, M96.661, M96.662, S32.301S, S32.302S, S32.311S, S32.312S, S32.314S, S32.315S, S32.391S, S32.392S, S32.401S, S32.402S, S32.411S, S32.412S, S32.414S, S32.415S, S32.421S, S32.422S, S32.424S, S32.425S, S32.431S, S32.432S, S32.434S, S32.435S, S32.441S, S32.442S, S32.444S, S32.445S, S32.451S, S32.452S, S32.454S, S32.455S, S32.461S, S32.462S, S32.464S, S32.465S, S32.471S, S32.472S, S32.474S, S32.475S, S32.481S, S32.482S, S32.484S, S32.485S, S32.491S, S32.492S, S32.591S, S32.592S, S32.601S, S32.602S, S32.611S, S32.612S, S32.614S, S32.615S, S32.691S, S32.692S, S32.89XS, S72.011S, S72.012S, S72.021S, S72.022S, S72.024S, S72.025S, S72.031S, S72.032S, S72.034S, S72.035S, S72.041S, S72.042S, S72.044S, S72.045S, S72.051S, S72.052S, S72.061S, S72.062S, S72.064S, S72.065S, S72.091S, S72.092S, S72.101S, S72.102S, S72.111S, S72.112S, S72.114S, S72.115S, S72.121S, S72.122S, S72.124S, S72.125S, S72.131S, S72.132S, S72.134S, S72.135S, S72.141S, S72.142S, S72.144S, S72.145S, S72.21XS, S72.22XS, S72.24XS, S72.25XS, S72.391S, S72.392S, S72.8X1S, S72.8X2S, S79.001S, S79.002S, S79.011S, S79.012S, S79.091S and S79.092S.Under ICD-10 Codes that Support Medical Necessity Group 2 Asterisk corrected T84.010A to now read T84.010A. Under ICD-10 Codes that Support Medical Necessity Group 3 added ICD-10 codes C40.21, C40.22, M05.49, M05.79, M05.89, M06.09, M06.89, M84.461S, M84.462S, M84.561S, M84.562S, M84.661S, M84.662S, M96.661, M96.662, M96.671, M96.672, S72.401S, S72.402S, S72.411S, S72.412S, S72.414S, S72.415S, S72.421S, S72.422S, S72.424S, S72.425S, S72.431S, S72.432S, S72.434S, S72.435S, S72.441S, S72.442S, S72.444S, S72.445S, S72.451S, S72.452S, S72.454S, S72.455S, S72.461S, S72.462S, S72.464S, S72.465S, S72.471S, S72.472S, S72.491S, S72.492S, S72.8X1S, S72.8X2S, S79.101S, S79.102S, S79.111S, S79.112S, S79.121S, S79.122S, S79.131S, S79.132S, S79.141S, S79.142S, S79.191S, S79.192S, S82.001S, S82.002S, S82.011S, S82.012S, S82.014S, S82.015S, S82.021S, S82.022S, S82.024S, S82.025S, S82.031S, S82.032S, S82.034S, S82.035S, S82.041S, S82.042S, S82.044S, S82.045S, S82.091S, S82.092S, S82.101S, S82.102S, S82.121S, S82.122S, S82.124S, S82.125S, S82.131S, S82.132S, S82.134S, S82.135S, S82.141S, S82.142S, S82.144S, S82.145S, S82.161S, S82.162S, S82.191S, S82.192S, S89.001S, S89.002S, S89.011S, S89.012S, S89.021S, S89.022S, S89.031S, S89.032S, S89.041S, S89.042S, S89.091S and S89.092S. Under ICD-10 Codes that Support Medical Necessity Group 4 added ICD-10 codes T84.042S and T84.043S.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
04/14/2016 R6 Under CMS National Coverage Policy added the section deleted “Title” X2 for the cited CFRs, added the section for Title 21 CFR, Chapter 1, Subchapter H, Part 888, corrected the title for 42 CFR §482.24 and CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 6, §6.5.2 and corrected the chapter cited to now read CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, §3.4.1.3. Under Coverage Indications, Limitations, and/or Medical Necessity added “and/or” to the tenth sentence of the fifth paragraph. Under Total Knee Arthroplasy (TKA)-Indications deleted the asterisk in the first sentence and the asterisk statement related to Associated Information-Documentation Requirements. In the third bullet added “a”. Under Total Hip Arthroplasty (THA) added the title “Indications” and deleted the asterisk in the first sentence and the asterisk statement related to Associated Information-Documentation Requirements. In the second sentence revised “Advance” to now read “Advanced”. In the third bullet added “a”. Under CPT/HCPCS Codes-Group 2 Paragraph corrected the title to now read “Revision of Total Hip Arthroplasty”. Under Associated Information-Documentation Requirements in the third bullet of the third paragraph added “a”. In the fourth bullet of the fourth paragraph deleted “…should be in the medical record as well.” Under Sources of Information and Basis for Decision corrected the spelling of the author name Osborne and deleted “et al” in the first journal citation. AAOS Symposium was deleted from the third journal citation. The access date was revised for the hyperlinks.
  • Provider Education/Guidance
  • Typographical Error
10/01/2015 R5 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.
  • Other (Bill type and/or revenue code removal)
10/01/2015 R4 Under CPT/HCPCS Codes split the codes into 4 groups instead of 2 groups, placing codes for Total Hip Arthroplasty in Group 1, Revised Hip Arthroplasty in Group 2, Total Knee Arthroplasty in Group 3 and Revised Knee Arthroplasty in Group 4. Under CPT/HCPCS Codes split the codes into 4 groups instead of 2 groups, placing codes for Total Hip Arthroplasty in Group 1, Revised Hip Arthroplasty in Group 2, Total Knee Arthroplasty in Group 3 and Revised Knee Arthroplasty in Group 4. Covered ICD-10 Codes placed ICD-10 codes under appropriate category. Removed the following ICD-10 codes under Group 1: M05.89, M06.09, M066.89, M08.09, M08.29, M08.89, M08.99, M80.051S,M80.052S, M80.851S, M80.852S, M84.351S,M84.352S, M84.451S, M84.452S, M84.551S, M84.552S, M84.651S, M84.652S, M96.661, M96.662, all the S32.301S-S79.092S codes. Group 2 Revision of Total Hip Arthroplasty, added the initial and subsequent encounter codes to each of the sequels codes. Group 3 Total Knee Arthroplasty added M05.061, M05.062, M08.061, M08.062, M08.261, M08.262, M08.461, M08.462, M08.861, M08.862, M08.961, M08.962, M12.061, M12.062, removed C40.21, C40.22, M05.49, M05.79, M05.89, M06.09, M06.89, M84.461S, M84.462S, M84.561S, M84.562S, M84.661S, M84.662S, M96.661, M96.662, M96.671, M96.672, all the S72.401S-S89.0912S codes. Group 4, Revision to Total Knee Arthroplasty added the initial and subsequent encounter codes to each of the sequels codes, added T84.53XA, T84.53XD, T84.53XS, T84.54XA, T84.54XD, T84.54XS and removed T84.142S and T84.043S. The ICD-9 LCD L33050 Total Joint Arthroplasty Notice period begins April 23, 2015.
  • Provider Education/Guidance
  • Automated Edits to Enforce Reasonable & Necessary Requirements
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R3 Under Sources of Information and Basis for Decision corrected web site address for archived document on AHRQ for Total Knee Replacement.
  • Other (Article was archived and moved to another web site address.)
10/01/2015 R2 Under ICD-10 codes that Support Medical Necessity removed ICD-10 code T84.061S as it did not belong in this section but in Group 1.Sources of Information and Basis for Decision added web site changes to place in correct format. This LCD was consolidated to be an A/B MAC LCD.
  • Provider Education/Guidance
  • Public Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R1 Under section titled CMS National Coverage Policy added short descriptors for associated citation. Under ICD-10 Codes That Support Medical Necessity multiple ICD-10 codes were removed from Group 1-Total Hip Arthroplasty and Group 2 - Total Knee Arthroplasty. The diagnosis list in the second sentence of the Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation was revised. Group 2-Total Knee Arthroplasty the verbiage was revised in the first sentence of the Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation to change “hip” to now read “knee”. Under ICD-10 Codes That Support Medical Necessity-Group 2-Total Knee Arthroplasty the diagnosis list in the second sentence of the Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation was revised. This revision becomes effective 10/01/2014.
  • Provider Education/Guidance
  • Other (Format changes. LCD was approved prior to the reviewing of the ICD-10 codes.)
  • Revisions Due To ICD-10-CM Code Changes

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56777 - Billing and Coding: Total Joint Arthroplasty
Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
07/06/2021 07/15/2021 - N/A Currently in Effect You are here
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Keywords

  • TJA
  • THA
  • TKA

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