Orthopedic Surgery Documentation Compliance Tips

July 24, 2023

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Written by Debra Rossi, CCS, CCS-P, CPC, CPMA

Joint Replacement Surgery

Prior to approving reimbursement for joint replacement surgery, CMS (and most commercial payers) typically require patients to undergo a period of conservative therapy or non-surgical treatments. The purpose of this requirement is to ensure that surgery is considered only when other treatment options have been exhausted or deemed ineffective.

The specific requirements for conservative therapy may include:

  1. Duration of Conservative Therapy: CMS may specify a minimum duration for conservative therapy, typically ranging from three to six months. During this period, patients are expected to undergo and document their participation in various non-surgical treatments aimed at managing joint pain and functional limitations. The duration requirement may vary depending on the specific joint being treated.
  2. Documentation of Non-Surgical Treatments: Providers are required to document the patient’s participation in conservative therapies, such as physical therapy, occupational therapy, use of assistive devices (e.g., canes, braces), weight loss programs, pharmacological interventions (e.g., nonsteroidal anti-inflammatory drugs), and other appropriate interventions. The medical records should reflect the type, frequency, and duration of these treatments.
  3. Lack of Improvement: Documentation should include that the conservative therapies have failed to provide significant or sustained improvement in the patient’s joint pain, activities of daily living, and overall quality of life. This may involve objective measurements, such as range of motion, functional assessments, pain scales, or patient-reported outcomes.
  4. Physician Assessment and Documentation: The surgeon is responsible for evaluating the patient’s response to conservative therapy and documenting the lack of improvement or inadequate response despite adherence to the recommended treatments. The physician should provide a clear clinical rationale for proceeding to joint replacement surgery.

Please note that the requirements outlined in the CMS NCD are specific to Medicare coverage for joint replacement surgeries. Private insurance plans may have their own coverage policies and criteria. Additionally, these requirements may be subject to updates and revisions, so it’s essential to consult the most current CMS guidelines or to seek guidance from the relevant healthcare authorities for the most up-to-date information.

Assistant At Surgery

When a primary surgeon utilizes an assistant at surgery documentation plays a vital role in ensuring proper communication, accountability, and compliance with regulatory requirements.

Documentation elements that a primary surgeon should provide when utilizing an assistant at surgery include:

  1. Surgical procedure documentation should include a detailed description of the surgical procedure provided including the preoperative diagnosis, specific steps taken, techniques employed, instruments used, and any modifications made during the surgery along with the surgical team, anesthesia details, significant findings, and post-operative diagnosis.
  2. Document the identity and credentials of the assistant at surgery. This includes their name, professional title (e.g., physician assistant, nurse practitioner), and any relevant certifications or qualifications. This documentation helps establish the qualifications and authority of the assistant.
  3. The primary surgeon should clearly outline the roles and responsibilities assigned to the assistant during the surgical procedure. This may include specific tasks, such as tissue handling, suturing, retracting, or other support functions. Documenting these roles helps clearly establish the medical necessity for the assistant and allows for supporting documentation needed for payer clarification when reimbursement is questioned.

It’s important to note the specific documentation requirements may differ based on local regulations, facility policies, and the requirements of insurance providers or regulatory bodies. Surgeons should consult the relevant guidelines and protocols specific to their jurisdiction and healthcare facility to ensure compliance with documentation requirements when utilizing an assistant at surgery.

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