DRG 470 - Major Joint Replacements or Reattachment of Lower Extremity

Published 01/23/2020

Major joint replacement or reattachment of the lower extremity (DRG 470) is Medicare’s top volume Medicare Severity (MS) – Diagnosis Related Group (DRG)s. 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

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