Focuses on lower extremity total joint arthroplasty

In many regions of the country, Medicare Administrative Contractors (MACs) have issued “improper payment denials” for orthopaedic procedures. These actions are based on unpublished or poorly distributed coverage policies that were developed without physician input. This is an issue of great concern to the American Association of Orthopaedic Surgeons (AAOS) and its members.

AAOS efforts to address this issue have included publishing multiple educational articles, producing meeting symposia for members, and successfully modifying an adverse coverage policy for lower extremity total joint arthroplasty in Florida. Recently, the AAOS Board of Directors took another step on behalf of members by appointing a Coverage Determinations Project Team, chaired by David Templeman, MD, to review and respond to all audit and coverage determination policies affecting orthopaedic procedures.

In direct response to the MAC-generated audits of major lower extremity total joint arthroplasty (DRG 470) claims, the Project Team has worked with the American Association of Hip and Knee Surgeons (AAHKS) to develop a model coverage policy for those procedures. The policy addresses indications for both total hip and total knee arthroplasty procedures—including failure of nonsurgical medical management—and the related documentation requirements. The model coverage policy has been distributed to all MAC medical directors and to the appropriate staff at the Centers for Medicare & Medicaid Services (CMS). The AAOS and AAHKS hope that the policy will be adopted by jurisdictions in which medical necessity and documentation criteria need to be clarified.

This is a strong step toward cultivating relationships with CMS officials who make policies affecting patient care. The AAOS will continue to review medical necessity and appropriateness determinations that relate to orthopaedic procedures and take appropriate steps to address any that would adversely affect patient care.

A link to the model coverage policy can be found on the AAOS Medicare Audits 101 webpage, www.aaos.org/medicare101. Login required.