Have you read MLN Matters® article SE1236 lately?
Coders may not be familiar with this article about documenting medical necessity for major joint replacements because it’s intended primarily for physicians, according to CMS.
It isn’t surprising that physicians are CMS’ intended audience for SE1236, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, an independent HIM consultant in Madison, Wis., and author of HCPro’s Documentation Improvement Guide to Physician E/M. “Who controls the documentation? The doctor does. The doctor decides whether the patient needs surgery. Hospitals are at the mercy of the doctors,” he says.
However, article SE1236 also applies to hospitals and coders, says Krauss. “It’s certainly of interest to hospitals, even more so because there’s more at risk,” he says.
Article SE1236 states:
Multiple auditing entities, including the Recovery Audit Contractors, Comprehensive Error Rate Testing [CERT] Contractors, and Medicare Administrative Contractors [MACs] have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.
“It’s right down to the first line of review,” says Krauss. “The carriers, FIs, and MACs are taking direction from the [Recovery Auditors] and Medicare.”
Coders and medical necessity
Article SE1236 reminds physicians to thoroughly document medical necessity for joint replacement surgery. This documentation is important with respect to patient care and avoiding denials, says Krauss.
CMS states in SE1236 that joint replacement surgery is reserved for patients whose symptoms have not responded to other treatments. Documentation should support the determination that major joint replacement surgery was reasonable and necessary. Such documentation includes:
- Chief complaint
- Detailed history of present illness,
- Physical examination based on signs and symptoms
- Any tests or diagnostic workups performed
- Final diagnosis
- Plan of care
- Ongoing clinical judgment
Progress notes that include conclusive statements without any supporting rationale are unacceptable, according to CMS.
“Osteoarthritis of the hip used to be sufficient, but the tides have turned, and physicians haven’t changed their documentation patterns,” says Krauss.
Documenting “failed conservative therapy” is also insufficient, and it should raise a red flag for coders. “Instead, [documentation] should be an accurate depiction of physicians’ medical decision-making. How did the doctor devise his or her plan of care? What did he or she consider when diagnosing the patient and recommending a course of treatment?” says Krauss.
In April, TrailBlazer Health Enterprises, LLC—the Part A and Part B Jurisdiction 4 MAC for Colorado, New Mexico, Oklahoma, and Texas—published Cross-Claim A/B Medical Review Questions and Answers on its website. One question and answer specifically addresses insufficient documentation related to failed conservative therapy.
Krauss offers this example of proper documentation:
Mrs. Jones is a 75-year-old patient well known to me who has been coming to me for years with progressive osteoarthritis. She is not able to walk without a walker. She lives in a three-story house and is unable to get to the bathroom on the second floor. We tried whirlpool therapy, a course of physical therapy. She improved slightly, but she still has ongoing and sometimes severe pain that prevents her from walking even with the use of her walker. Her range of motion has decreased 50% over the last year. We tried pain injections for a six month course. These were not successful. A decision was made to perform a hip replacement in order to increase her activities of daily living and reduce the risk of decubitus ulcer and possible falls, particularly since she lives alone and does not have good social support.
Preparing for ICD-10-PCS
Physicians must thoroughly document medical necessity, and they will need to start documenting information necessary for ICD-10-PCS, says Lynn Marlow, BS, RHIT, CCS, auditing and education consultant at TrustHCS in Springfield, Mo.
For example, ICD-10-PCS requires laterality for both hip and knee replacements. For hip replacements involving synthetic substitutes, ICD-10-PCS also requires the type of bearing surface used (i.e., metal on polyethylene, metal on metal, ceramic on ceramic, or ceramic on polyethylene). This information is reported as the seventh character in the ICD-10-PCS code. Also note that the sixth character denotes the device (i.e., the replacement). ICD-10-PCS considers the replacement a device because it remains in the body after the procedure is completed.
Marlow says physicians don’t often document the type of bearing surface used. However, coders and clinical documentation improvement (CDI) specialists can advocate now for this information.
Article SE1236 and other resources
As coders review documentation of major joint replacements to ensure compliant coding, they should also be on the lookout for medical necessity as well as details necessary for ICD-10-PCS.
Article SE1236 provides actual examples of documentation that meet medical necessity for joint replacement surgery. Although the examples don’t describe all of the necessary documentation required for this type of surgery, coders and CDI specialists can use the information for educational purposes.
The MLN Matters article also provides this example of documentation that may result in a denied claim:
Mrs. Smith is a female, age 70, with chronic right knee pain. She states she is unable to walk without pain, and pain meds do not work. Therefore, she needs a total right knee replacement.
Coders should use article SE1236 as a road map for CDI, says Krauss. Retrieve and review 10 records that include documentation of major joint replacement surgeries (i.e., hip or knee). How does documentation in those records compare with the examples in the article? Address any deficiencies directly with physicians, he says.
Case managers should automatically review hospital and office note records when major joint replacement surgeries are scheduled to ensure that the records include a detailed history of present illness, relevant physician office notes, radiology workups, and more, he says.
Article SE1236 should serve as a reminder to coders that if they observe patterns of insufficient documentation—particularly documentation that jeopardizes medical necessity—they should bring it to the attention of a case manager or coding manager, says Krauss. Not doing so indirectly contributes to denials. All allied health professionals, including coders, have a duty and vested interest in avoiding costly retrospective denials from Medicare contractors, he says.
Coders are in an ideal position to identify documentation insufficiencies because they’re already reviewing records in their entirety to code hospital stays, says Krauss. Coders shouldn’t simply code conditions or procedures that they know will ultimately be denied. “There’s no point in getting something billed if you’re only going to get the money taken back,” he says.
Use article SE1236 to educate physicians directly, says Marlow. “It’s definitely something that would be of interest to them,” she says.
For example, one of Marlow’s hospital clients created “Scrub Sink News,” a compilation of quick tips and educational information for physicians posted above scrub sinks in operating rooms and regularly updated by coders and CDI staff. It became a convenient, concise, nonintrusive way to educate physicians, says Marlow.
Also consider the following resources with respect to physician education:
- Joint Replacement Documentation Notice, published by TrailBlazer on March 14, 2012. This document includes examples of end-stage joint disease documentation that may help support payment for knee or hip joint replacement-related hospital care.
- Medicare Report, published in March 2012 by Novitas Solutions, Inc., the Part A MAC for Delaware, New Jersey, Pennsylvania, Maryland, the District of Columbia, Arkansas, Louisiana, and Mississippi. This report includes specific documentation requirements for total knee and total hip replacements.
Editor’s note: This article was originally published in the December 2012 issue ofBriefings on Coding Compliance Strategies.