Advocacy News
September 18, 2012



CMS Publishes Guidance on Documenting Medical Necessity for Total Joint Replacements

Bonefied News

AAOS Hosts First Annual Welcome Back Congress Reception

A Recap of the Democratic National Convention

AAOS Attends Democratic, Republican Conventions

AAOS Submits Comments to CMS on Proposed Rule for 2013 Payments to Hospital Out Patient Departments and Ambulatory Surgical Centers

Court: Providers Cannot Challenge Medicare Payment Audits Deemed to Have "Good Cause."

FDA Report Proposes Strengthening Postmarket Medical Device Surveillance System

AAOS Sends Letter to House and Senate Regarding Pending Sequestration and SGR Cuts

Victory on LCD Denying Post Single Joint Replacement Admissions to IRFs

FDA to Hold Panel Meeting on Posterior Cervical Screws

Presidential Polling


AAOS website

AAOS Calendar

House of Representatives Legislative Activities


CMS Publishes Guidance on Documenting Medical Necessity for Total Joint Replacements

imageOn September 17th, the Centers for Medicare & Medicaid Services published an MLN Matters article entitled “Documenting Medical Necessity for Major Joint Replacement (Hip and Knee).”  While the agency cautioned that use of the information contained in the article is not mandatory and does not guarantee payment, it does provide highly anticipated guidance from CMS on ways to improve compliance with documentation requirements.  The article can be found here.

“The AAOS recognizes CMS’s efforts to reduce Medicare payment errors so that the program can remain solvent for musculoskeletal patients.  However, these efforts must not hinder orthopaedic surgeons’ ability to provide valuable services like hip and knee replacement surgery,” said John R. Tongue, MD, President of the American Association of Orthopaedic Surgeons.  “With the new audit activity by CMS, the AAOS urged the publication of documentation guidance for orthopaedic surgeons performing total hip and total knee replacement surgeries, so that claims are not unreasonably denied.”

CMS emphasizes the importance of documenting failed conservative treatments in a detailed manner.  One of the first statements made in the article is that: “CMS recognizes that joint replacement surgery is reserved for patients whose symptoms have not responded to other treatments.”  CMS then states, in bold, “Progress notes consisting of only conclusive statements should be avoided.”  Please see the box below for more detailed examples of the type of information CMS and its auditors expect to see in your records.  The full text of the article also includes examples of both poorly documented claims and well documented claims.

“The AAOS appreciates the guidance that CMS has recently released in its publication MLN Matters.  This valuable information will help AAOS in its efforts to educate our members so that orthopaedic surgeons can continue to provide clarifying documentation for Medicare claims,” added President Tongue. 

The AAOS has advocated before local Medicare administrative contractors (MACs), CMS, and Congress in order to seek clarification on documentation guidelines in the face of increased audit activity.  Please visit our Medicare Audits 101 webpage at in order to learn more about our advocacy efforts, report audit activity to the AAOS and view our model local coverage determination (LCD).  In the absence of formal guidelines, such as those provided by an LCD, we will use this article to educate members about best practices in documenting medical necessity.

  Examples of Information Orthopaedic Surgeons Should Include in Medical Records

  • Description of the pain (onset, duration, character, aggravating, and relieving factors);
  • Limitation of Activities of Daily Living (ADLs) - specify;
  • Safety Issues (e.g. falls)
  • Contraindications to non-surgical treatments;
  • Listing and description of failed non-surgical treatments such as:
    • Trial of medications (e.g. NSAIDs);
    • Weight loss;
    • Physical Therapy;
    • intra-articular injections;
    • Braces, orthotics or assistive devices.
Physical Examination
  • Deformity;
  • Range of motion;
  • Crepitus;
  • Effusions;
  • Tenderness;
  • Gait description (with/without aides).
  • Results of applicable investigations (e.g. plain radiographs).
Clinical Judgement
  • Reasons for deviating from a stepped-care approach.