Resources to Support Appeals of TKA Code Denials

January 2018 marked a major win for AAOS’ advocacy efforts, when the Centers for Medicare & Medicaid Services (CMS) removed the Current Procedural Terminology (CPT®) code 27447, describing the total knee arthroplasty (TKA) procedure, from the Medicare Inpatient-Only (IPO) list.

The policy change, which was made in the 2018 Medicare Outpatient Prospective Payment System (OPPS) Final Rule (82 Fed. Reg. 52,523) published November 13, 2017, allows for payment of the TKA procedure in either the hospital inpatient or outpatient setting. This guidance reiterates that the surgeon is the final arbiter of the setting of care and provides several clinical case studies to guide how CMS’ Quality Improvement Organizations (QIOs) will review claims based on the two-midnight rule.

The TKA resources below are intended to provide AAOS members with strategic knowledge and best practices to navigate the Medicare change in policy regarding TKA and to support surgeon efforts in appeals for inappropriate denials for TKA, CPT code 27447.

Appeal Letter Template

Our appeal letter template may be used to appeal inappropriate denials for TKA, CPT code 27447. It offers the framework needed to support appeals for denied TKAs and may be altered to fit the specific situation.

Additional CMS Guidance & FAQs

Find a comprehensive list of questions and answers regarding the removal of TKA from the Medicare inpatient-only (IPO) list. PDF format for ease of download and/or print.

The January 2019 special edition article from MLN Matters provides guidance from CMS on TKA procedures and the application of the two-midnight rule.