SUPERSEDED Local Coverage Determination (LCD)

Total Joint Arthroplasty

L36039

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Superseded
To see the currently-in-effect version of this document, go to the section.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L36039
Original ICD-9 LCD ID
Not Applicable
LCD Title
Total Joint Arthroplasty
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL36039
Original Effective Date
For services performed on or after 12/01/2015
Revision Effective Date
For services performed on or after 10/10/2019
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
10/16/2015
Notice Period End Date
11/30/2015

CPT codes, descriptions, and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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Issue

Issue Description
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):
Section 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.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:
Title 21 CFR, Chapter 1, Subchapter H, Part 888 orthopedic devices, arthroscope.

Title 42 CFR §482.24 documentation for medical records.

IOM:
CMS Publication 100-08, Medicare Program Integrity Manual:
Chapter 6, §6.5.2, Medical Review of Acute IPPS Hospital or LTCH.
Chapter 13, §3.4.1.3, diagnosis code requirement.

CMS Publication 100-02, Medicare Benefit Policy Manual:
Chapter 7- Home Health Services, §40.2.1 - General Principles Governing Reasonable and Necessary Physical Therapy, Speech-Language Pathology Services, and Occupational Therapy, defines activities of daily living (ADLs).

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract:
Joint replacement surgery, also known as arthroplasty, has proved to be an important medical advancement. Arthroplasty surgery is most commonly performed for diseases which affect the function of the hip joint and knee joint, but is also performed on ankles, shoulders, and phalanges. In addition, the arthroplasty may be total (involving the entire joint) or partial (involving less than the entire joint).

Note: This local coverage determination (LCD) only addresses total hip and knee replacement surgery. 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 total knee arthroplasty.

Total Knee Arthroplasty (TKA)

The knee joint 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 normally covered with articular cartilage and are bathed in synovial fluid. The most common reason for knee arthroplasty is arthritis of the knee joint. Arthritis may cause pain, stiffness, or other symptoms which limit normal activities such as walking, squatting, and climbing stairs. Additional indications for knee arthroplasty include osteonecrosis, malignancy, and other degenerative conditions. The goal of knee arthroplasty is to relieve pain and improve or increase patient function.

Total Hip Arthroplasty (THA) (TKA)

The hip joint is 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. Hip arthroplasty is most often performed due to symptoms arising from arthritis, osteonecrosis, malignancy, and degenerative conditions. The goal of hip arthroplasty is to relieve pain and improve or increase patient function.

Revision Arthroplasty

Revision arthroplasty is performed on an individual who has had a prior hip or knee arthroplasty. Revision arthroplasty may be needed when pain or other symptoms occur as a result of failure of the prior surgery. Failure may occur as a result of infection of the joint, bone loss in the structures supporting the prosthesis, fracture, aseptic loosening of the components, wear of the prosthetic components, and for other reasons.

Indications:

Total Knee Arthroplasty (TKA)

TKA is considered reasonable and necessary for individuals with one or more of the following*:

  1. Advanced Joint disease and all of the following (a,b,c):
    1. The joint disease is evidenced by conventional radiography, or magnetic resonance imaging (MRI)*; and
    2. Pain or functional disability attributable to the advanced joint disease; and
    3. Unsuccessful non-surgical medical management*, when appropriate, and attempted for a minimum of 3 months. (When non-surgical medical management is not appropriate, the medical record must clearly document the basis for that conclusion);
      or
  2. Failure of a previous osteotomy; or
  3. Distal femur fracture; or
  4. Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or
  5. Failure of previous unicompartmental knee replacement; or
  6. Avascular necrosis of the knee; or
  7. Proximal tibia fracture


*See Documentation Requirements in the attached Billing and Coding Article for additional information.


Replacement/Revision Knee Arthroplasty

Replacement/Revision knee arthroplasty is considered reasonable and necessary for individuals with one or more of the following*:

  • Loosening of one or more component; or
  • Fracture or mechanical failure of one or more components, or
  • Infection, or
  • Periprosthetic fracture of distal femur, proximal tibia or patella, or
  • Progressive or substantial periprosthetic bone loss, or
  • Bearing surface wear with symptomatic synovitis, or
  • Implant or knee misalignment, or
  • Knee stiffness/arthrofibrosis, or
  • Tibiofemoral instability, or
  • Extensor mechanism instability


*See Documentation Requirements in the attached Billing and Coding Article for additional information.

Total Hip Arthroplasty (THA)

THA is considered reasonable and necessary for individuals with one or more of the following*:

  1. Advanced Joint disease and all of the following (a,b,c):
    1. The joint disease is evidenced by conventional radiography, or magnetic resonance imaging (MRI) *; and
    2. Pain or functional disability attributable to the advanced joint disease; and
      c
    3. Unsuccessful non-surgical medical management*, when appropriate and attempted for a minimum of 3 months. (When non-surgical medical management is not appropriate, the medical record must clearly document the basis for that conclusion);
      or
  2. Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; or
  3. Avascular necrosis (osteonecrosis of femoral head); or
  4. Fracture of the femoral neck; or
  5. Acetabular fracture; or
  6. Non-union or failure of previous hip fracture surgery; or
  7. Mal-union of acetabular or proximal femur fracture


*See Documentation Requirements in the attached Billing and Coding Article for additional information.

Replacement/Revision Hip Arthroplasty

Replacement/Revision knee arthroplasty is considered reasonable and necessary for individuals with one or more of the following*:

  • Loosening of one or both components; or
  • Fracture or mechanical failure of the implant; or
  • Recurrent or irreducible dislocation; or
  • Infection; or
  • Treatment of a displaced periprosthetic fracture; or
  • Clinically significant leg length inequality not amenable to conservative management; or
  • Progressive or substantial bone loss; or
  • Bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction; or
  • Clinically significant audible noise; or
  • Adverse local tissue reaction.


*See Documentation Requirements in the attached Billing and Coding Article for additional information.

Bilateral Surgery

When bilateral TKA or bilateral THA is performed, the criteria listed above and documentation requirements below apply to the each joint upon which surgery is performed.

Limitations

TKA or THA is not considered reasonable or necessary when none of the criteria above are met.

TKA or THA is not considered reasonable or necessary when one or more of the following contraindications are present:

  • Active infection of the hip or knee joint or active systemic bacteremia; and/or
  • Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned surgical site of the hip or knee; and/or
  • Rapidly progressive neurological disease except in the clinical situation of a concomitant displaced femoral neck fracture

 

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information
N/A
Sources of Information

Other MAC LCDs:, Palmetto GBA Local Coverage Determination DL33050 for Total Joint Arthroplasty; Noridian Healthcare Solutions, LLC LCD L33494, Total Joint Arthroplasty; and First Coast Service Options, Inc. LCD L32078 for Major Joint Replacement (Hip and Knee); whose sources include:

Ackerman IN, Bennell KL, Osbourne RH, et al. 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

Agency for Healthcare Research and Quality (AHRQ). TotalJoint

Dennis DA, Berry DJ, Engh G. AAOS Symposium: Revision total knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2008:16(8):442-454.

Emedicine. Total Knee Arthroplasty Accessed 9/9/2014.

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.

InterQual® 2011 Procedures Adult Criteria, Total Joint Replacement, Knee and Hip & Removal and Replacement, Total Joint Replacement Knee and Hip. McKesson Corporation.

Milliman Care Guidelines® 2011. Inpatient and Surgical Care 15th Edition. Knee Arthroplasty and Hip Arthroplasty. Milliman Care Guidelines LLC.

O’Connor M. 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.

Orthopedic Connection (2013) Total Knee Replacement Accessed 9/9/2014.

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.

U.S. National Library of Medicine, National Institute of Health. Hip joint replacement Accessed 9/9/2014.

Bibliography

N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
10/10/2019 R3

Consistent with Change Request 10901, all coding information, National coverage provisions, and Associated Information (Documentation Requirements, Utilization Guidelines) have been removed from the LCD and placed in the related Billing and Coding Article, A57428. There has been no change in coverage with this LCD revision.

  • Revisions Due To Code Removal
12/01/2015 R2 Removed obsolete source listing for National Guideline Clearinghouse: Medical Management of Adults with Osteoarthritis.
  • Other
12/01/2015 R1 The LCD was revised during the Notice period and is effective 12/1/2015. Based on ICD-10 coding considerations and comments received on the draft LCD, diagnosis codes have been removed from the final LCD.
  • Other
N/A

Associated Documents

Attachments
N/A
Related National Coverage Documents
N/A
Public Versions
Updated On Effective Dates Status
03/31/2023 10/10/2019 - N/A Currently in Effect View
10/04/2019 10/10/2019 - N/A Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • TJA

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