Pre-Payment Review Results for Total Hip Arthroplasty for October to December 2024
Pre-Payment Review Results for Total Hip Arthroplasty for Current Procedural Terminology (CPT ®) Code 27130, Targeted Probe and Educate (TPE) for October to December 2024
The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for CPT® code 27130 Total Hip Arthroplasty. The reviews with edit effectiveness are presented here for North Carolina, South Carolina, Virginia and West Virginia.
Cumulative Results
|
Number of Providers with Edit Effectiveness |
Providers Compliant Completed/Removed After Probe |
Providers Non-Compliant Progressing to Subsequent Probe |
Providers Non-Compliant/Removed for Other Reason |
|---|---|---|---|
|
24 |
24 |
0 |
0 |
|
Number of Claims with Edit Effectiveness |
Number of Claims Denied |
Overall Claim Denial Rate |
Total Dollars Reviewed |
Total Dollars Denied |
Overall Charge Denial Rate |
|---|---|---|---|---|---|
|
480 |
4 |
1% |
$4,818,429.34 |
$41,848.07 |
1% |
Probe One Findings
|
State |
Number of Providers with Edit Effectiveness |
Providers Compliant Completed/Removed After Probe |
Providers Non-Compliant Progressing to Subsequent Probe |
Providers Non-Compliant/Removed for Other Reason |
|---|---|---|---|---|
|
N.C. |
4 |
4 |
0 |
0 |
|
S.C. |
5 |
5 |
0 |
0 |
|
Va. |
13 |
13 |
0 |
0 |
|
W.Va. |
2 |
2 |
0 |
0 |
|
State |
Number of Claims with Edit Effectiveness |
Number of Claims Denied |
Overall Claim Denial Rate |
Total Dollars Reviewed |
Total Dollars Denied |
Overall Charge Denial Rate |
|---|---|---|---|---|---|---|
|
N.C. |
80 |
0 |
0% |
$819,534.92 |
$0 |
0% |
|
S.C. |
100 |
0 |
0% |
$1,032,691.05 |
$0 |
0% |
|
Va. |
260 |
4 |
2% |
$2,589,395.68 |
$41,848.07 |
2% |
|
W.Va. |
40 |
0 |
0% |
$376,807.69 |
$0 |
0% |
Risk Category
The risk categories for CPT® code 27130 Total Hip Arthroplasty are defined as:
| Risk Category | Error Rate |
|---|---|
| Minor | 0–20% |
| Major | 21–100% |
Figure 1. Risk Category for Total Hip Arthroplasty.
Top Denial Reasons
| Percent of Total Denials | Denial Code | Denial Description | Number of Occurrences |
|---|---|---|---|
| 43% | 5DMDP, 5HMDP | Dependent Services Denied (Qualifying Service Denied Medically) | 3 |
| 43% | 5D164, 5H164 | No Documentation of Medical Necessity | 3 |
| 14% | 5D169, 5H169 | Insufficient Documentation | 1 |
Denial Reasons and Recommendations
5DMDP/5HMDP — Dependent Ser vices Denied (Qualifying Service Denied Medically)
Reason for Denial
The dependent services will not be covered if the qualifying service has been denied. For example, the service was denied as documentation did not support medical necessity, therefore all other charges associated with the service under review cannot be allowed and will be denied as dependent to the medical denial of the qualifying service.
How to Avoid This Denial
- Ensure the documentation provided supports the services were reasonable and medically necessary for the treatment of the beneficiary
- Ensure all records are properly and legibly signed
- Ensure documentation supports the service(s) was rendered
Resources
- 42 (CFR) Code of Federal Regulations — Section 410.32
- CMS Internet-Only Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6 (PDF)
5D164/5H164 — No Documentation of Medical Necessity
Reason for Denial
This claim was denied because the documentation submitted does not support the medical necessity of the service reviewed. The records did not contain any covered condition/indication, symptomology or diagnostic results that would support the service was reasonable and necessary for the treatment of the beneficiary.
How to Avoid This Denial
- Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:
- A covered indication or condition for the service billed
- A physician/NPP is managing the care of the covered indication or condition billed is documented in the record
- Any medical history that supports a need for the service
- Any diagnostic results or symptomology that supports a need for the service
- Legible documentation
- Submit all documentation to support ongoing skills of a qualified therapist were required to complete the treatment and that the initiation of therapy treatment services were medically necessary
- ABN is valid, complete, and submitted in the record if applicable
- A legible physician or nonphysician provider (NPP) signature is required on all documentation necessary to support medical necessity
- Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis
- Submit treatment note documentation that contains date of treatment, description of modality/procedure to support accurate billing, total treatment minutes/ total timed code treatment minutes and signature of qualified professional
- Documentation to include the therapy discharge note and summary
- All documentation submitted is legible
Resources
- Code of Federal Regulations, 42 CFR — Section 409.44(c)(2), 410.60(c)(2)
- Social Security Act (SSA) — Section 1862(a)(1)(A)
- CMS IOM, Pub. 100-02, Medicare Program Integrity Manual, Chapter 15, Section 220.2, 220.2A, 220.2B, 230.1C and 230.2C (PDF)
- CMS IOM, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4, 3.4.1.3, 3.6.2.1, 3.6.2.2 (PDF)
5D169/5H169 — Insufficient Documentation
Reason for Denial
This claim was partially or fully denied because the documentation submitted is insufficient for the services billed.
How to Avoid This Denial
- Submit all documentation related to the services billed
- Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed
- Ensure that the documentation is complete with proper authentication and the signature is legible
Resources
- Social Security Act 1815
- Title 42 Code of Federal Regulations — Section 424.5(a)(6)
- CMS IOM, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 C (PDF)
Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form (PDF).
Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date.