DRG 470: Major Joint Replacements or Reattachment of Lower Extremity

Major joint replacement or reattachment of the lower extremity (DRG 470) is Medicare’s top volume Medicare Severity (MS) – Diagnosis Related Group (DRG). Due to the high volume of these claims, CMS has had multiple auditing entities reviewing claims for these MS-DRGs, including the Recovery Auditors, Comprehensive Error Rate Testing (CERT) Contractors, and Medicare Administrative Contractors (MACs), reviewing claims for these MS-DRGs. The findings have demonstrated very high paid claim error rates among both hospital and professional claims associated with major joint replacement surgery.

Top Denials for DRG 470

• No physician order/intent to admit to inpatient status present
• Documentation was not present to support dates of services as billed/or correct beneficiary
• Operative procedure was not included in the documentation submitted
• No documentation of conservative measures/treatments failed (does not support medical necessity as listed in coverage requirements)
• No documentation of pain impacting the functional ability of beneficiary despite conservative treatment
• No X-ray, CT or MRI results submitted to support operative procedure performed
• All or part of the claim was billed in error (documentation does not support the claim as billed)

To Avoid Denials, Include the Following in the Medical Record:

• Description of the pain (onset, duration, character, aggravating, and relieving factors)
• Limitation of specific ADLs
• Safety issues (falls, for example)
• Contraindications to non-surgical treatments
• 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 and/or home exercise plans
  • Intra-articular injections
  • Assistive devices (for example, cane, walker, braces (specify type of brace), and orthotics)

Objective Findings to Include in the Physical Examination

• Any deformity
• Range of motion
• Crepitus
• Effusions
• Tenderness
• Gait description (with or without mobility aides)
• Include any test that were given (plain radiography and pre-operative imaging studies)

Pre-Operative Documentation Should Include Specific Conditions

• Osteoarthritis (mild, moderate, severe)
• Inflammatory arthritis (rheumatoid arthritis, psoriatic arthritis)
• Failure of previous osteotomy
• Malignancy of distal femur, proximal tibia, knee joint, soft tissues
• Failure of previous unicompartmental knee replacement
• Avascular necrosis of knee
• Malignancy of the pelvis or proximal femur or soft tissues of the hip
• Avascular necrosis of the femoral head
• Fractures (for example: distal femur, femoral neck, acetabulum)
• Nonunion, malunion or failure of previous hip fracture surgery
• Osteonecrosis

Post-Operative Documentation

• Operative report for the procedure, including observed pathology
• Daily progress notes for inpatients
• Discharge plan and discharge orders

Resources

• CMS Learning Network: Major Joint Replacement (Hip or Knee) (PDF)
• CMS website