Knee and hip replacements are on the rise.  In my family and circle of friends there have been many who have received one or both of these surgeries.  I can say with certainty that they suffered with the pain and debility for quite some time, some of them years.  It takes a leap of faith to make the decision to have the surgery performed.  Then why is Centers for Medicare & Medicaid Services (CMS) denying payment for the inpatient admission and stay?  It cannot be because the patient did not medically need the surgery.  Certainly they have suffered.  But the procedure code is coming back as denied because it was deemed not medically necessary and reasonable.  The answer, of course, is lack of documentation.

The inpatient payment is being denied based on the lack of documentation by the provider supporting the signs and symptoms experienced by the patient.  The following criterion for a total knee replacement procedure supports medical necessity:

  • Documentation of pain at the knee, including the level of pain and worsening of pain
  • Pain that is increased with activity
  • Pain that is increased with weight bearing
  • Pain that interferes with activities of daily living
  • Pain with passive range of motion
  • Limited range of motion
  • Crepitus
  • Joint effusion/swelling

In addition there should be x-rays with at least two of the following findings:

  • Subchondral cysts
  • Subchondral scierosis
  • Periarticular osteophytes
  • Joint subluxation
  • Joint space narrowing

The documentation for knee and hip replacement must also include the attempt of medications or the contraindication of medication due to the patents’s inability to tolerate it.  There must also be an attempt of physical therapy or external joint support (cane or walker) greater than or equal to 12 weeks or documentation as to why the patient could not tolerate physical therapy.  The criteria for x-rays for knee replacement and hip replacement are the same.

The following criterion for a total hip replacement procedure supports medical necessary.

  • Pain at hip
  • Pain increased with activity
  • Pain increased with weight bearing
  • Pain that interferes with activities of daily living
  • Pain with passive range of motion
  • Limited range of motion
  • Antalgic gait

The auditing of these procedures does not stop at the hospital level.  Documentation must be provided by the physician office.  This includes all progress notes that support medical necessity.

CMS is recouping overpayments due to the lack of documentation.  This brings clarity to the statement, “If it wasn’t documented, it didn’t happen.”