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
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