CMS Documentation Requirements for Hip and Knee Replacement Surgery

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CMS has published a booklet on this procedure.

Recently I was asked to assist with an audit that was to focus on clinical documentation for major joint replacement surgery, specific to the hips and knees.

Of course, I immediately thought about some information and guidance (a booklet) published by the Centers for Medicare & Medicaid Services (CMS) in November 2020, though it originated in 2017. With the volume of attention devoted toward the COVID-19 pandemic and the related changes to healthcare policies, procedures, and practices, you might not have gotten into the CMS 2020 guidance (Medicare Learning Network, or MLN) and how it applies to your facility operations and practices – so now is the time (see the link at the end of this article).

Major joint replacement or reattachment is a high-volume Medicare Severity Diagnosis Related Group (MS-DRG). CMS has had many auditing entities – including the Recovery Auditors (RAs), Comprehensive Error Rate Testing (CERT) contractors, the Beneficiary and Family Centered Quality Improvement Organization (BFC-QIO), and Medicare Administrative Contractor (MAC) – performing reviews, all focusing on these joint replacement MS-DRGs. Medical necessity, quality of care, and compliance are always aspects of following CMS guidance.

This Major Joint Replacement CMS guidance outlines what specific clinical documentation should be included in the history and physical (H&P) and pre-/post-operative documentation, which is something with which physicians (providers) and hospital staff should be very familiar. This CMS information would be great to include in provider education activities, such as those conducted by coding and/or clinical documentation improvement (CDI). 

The following outlines the CMS H&P documentation elements listed in the booklet.

The history should include information such as:

  • A description of the pain (onset, duration, character, aggravating, and relieving factors);
  • Limitation of specific activities of daily living (ADLs);
  • Safety issues (for example, falls);
  • Contraindications to non-surgical treatments;
  • A listing, description, and outcomes of failed non-surgical treatments, such as – trial of medications (for example, nonsteroidal anti-inflammatory drugs (NSAIDs) – weight loss – physical therapy – occupational therapy – intra-articular injections; as well as:
    • Braces, orthotics or assistive devices;
    • Physical therapy and/or home exercise plans; and
    • Assistive devices (for example, cane, walker, braces and types, and orthotics).

The physical examination should describe the joint examination with detailed objective findings, such as:

  • Any deformity;
  • Range of motion;
  • Crepitus;
  • Effusions;
  • Tenderness; and
  • Gait description (with or without mobility aides).

CMS further states that investigations should include the results of applicable tests (for example, plain radiographs and pre-operative imaging studies). Consultation records should also be kept for any associated co-morbidities, for example, cardiology consult, or diabetes management pre-, intra-, and post-operatively.

In addition, CMS also wants documentation to include “a statement of clinical judgment with reasons for deviating from a stepped-care approach.”

The CMS Major Joint Replacement booklet also contains guidance regarding pre- and post-operative documentation, and information to include in the health record (medical record), for which it provides several examples.

One other item that CMS describes in this booklet is the post-acute care transfer policy (PACT), which pays as transfers all cases assigned to certain DRGs if the patient was discharged to a psychiatric hospital or unit, an inpatient rehabilitation hospital or unit, a long-term care hospital, a children’s hospital, a cancer hospital, a skilled nursing facility (SNF), or a home health agency (HHA). This is another area on which to focus to achieve accuracy and compliance when conducting reviews. Also, remember that validation of the discharge disposition status code is important to include in your reviews/audits.

If your facility (hospital) performs these surgeries, reading over the CMS booklet would be a wise step to take. Run a data report on the specific MS-DRGs for a year and determine your volume; this will be helpful in conducting a review/audit. Here is a list of MS-DRG upon which you can focus:

  • 469   Major Joint Replacement or Reattachment of Lower Extremity With MCC
  • 470   Major Joint Replacement or Reattachment of Lower Extremity Without MCC
  • 461   Bilateral or Multiple Major Joint Procedures of Lower Extremity With MCC
  • 462   Bilateral or Multiple Major Joint Procedures of Lower Extremity Without MCC
  • 466   Revision of Hip or Knee Replacement with MCC
  • 467   Revision of Hip or Knee Replacement with CC
  • 468   Revision of Hip or Knee Replacement without MCC/CC

In addition, even if you have already read this CMS booklet, look over the November 2020 version and utilize it when conducting a review/audit – and determine if your clinical documentation is meeting the CMS Major Joint Replacement requirements. Both coding and CDI professionals would be ideal to conduct this type of review and engage in ongoing education.

The Medicare Learning Network®, MLN Connects®, and MLN Matters® have registered trademarks of the U.S. Department of Health & Human Services (HHS).

About the author: Gloryanne has worked in the HIM Coding and CDI areas of healthcare for more than 40 years. She currently is an independent Coding and CDI Consultant.

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Gloryanne Bryant, RHIA, CDIP, CCS, CCDS

Gloryanne is an HIM coding professional and leader with more than 40 years of experience. She has an RHIA, CDIP, CCS, and a CCDS. For the past six years she has been a regular speaker and contributing author for ICD10monitor and Talk Ten Tuesdays. She has conducted numerous educational programs on ICD-10-CM/PCS and CPT coding and continues to do so. Ms. Bryant continues to advocate for compliant clinical documentation and data quality. She is passionate about helping healthcare have accurate and reliable coded data.

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