Total Joint Arthroplasty
Insufficient documentation causes most improper payments. Insufficient documentation means that something was missing from the medical records.
Providers can help prevent CERT errors on total joint arthroplasty by ensuring the medical record contains documentation that fully supports the medical necessity and justification of the procedure performed.
When the procedure is indicated for advanced joint disease, the following should be documented in the medical record:
Arthritis of the knee or hip supported by X-ray or MRI. The X-ray or MRI should demonstrate one of the following:
- subchondral cysts,
- subchondral sclerosis,
- periarticular osteophytes,
- joint subluxation,
- joint space narrowing,
- avascular necrosis, or
- bone on bone articulations
The extent to which pain or functional disability interferes with ADLs (functional disability), increases with activity or increases with weight bearing. ADLs include, but are not limited to, dressing, feeding, toileting, grooming, physical ambulation (including balance/risk of falls) and bathing.
Documentation of unsuccessful nonsurgical medical management. Documentation should establish a history of a reasonable attempt at conservative therapy as appropriate for the patient in their current episode of care. Clinically appropriate nonsurgical medical management typically includes one or more of the following:
- anti-inflammatory medications and/or analgesics;
- flexibility and muscle strengthening exercises;
- supervised physical therapy;
- assistive device use;
- reasonable activity restrictions;
- weight reduction as appropriate;
- therapeutic injections into the joint as appropriate.
Nonsurgical medical management may be inappropriate, ineffective or counterproductive when one or more of the following is present:
- bone on bone articulation;
- severe deformity;
- severe pain (particularly at rest) and significant disabling interference with activities of daily living.
Related Content
- Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 110.1 C (Provider Retention of Health Insurance Records/Medical Record Material)
- CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (Signature Requirements)
- CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.5 (Medical Review of Inpatient Hospital Claims Part A Payment) and Section 6.5.3 (DRG Validation Review)
- Billing and Coding Article: Total Joint Arthroplasty (A57428)
- National Government Services Local Coverage Determinations (LCD) & Articles
Reviewed 11/14/2024
Helpful Resources
CERT Denial Finder
CERT Task Force
CMS CERT Compliance
Options for submitting medical records to CERT
Include barcode coversheet with all submissions.
Option to submit Electronic using esMD:
More information on esMD can be found atwww.cms.gov, be sure to route medical records to the CERT Contractor at:
804-261-8100
Option to Mail:
CERT Documentation Center
Attn: CID
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
Providers mailing documentation via CD should send the password toCERTmail@empower.ai; use the CID number in the subject line of your email (no PHI).
Option to email:
Email documentation in an encrypted emailed to CERT atCERTmail@empower.ai. Password should be submitted in separate email, use the CID number in the subject line of your emails (no PHI).
Questions about medical record submissions
CERT Customer Service:
443-663-2699
Toll Free: 888-779-7477
CERTprovider@empower.ai
Questions about CERT reviews
NGS Provider Contact Center
Select “Contact Us” for phone number per state and jurisdiction
Helpful Resources
CERT Denial Finder
CERT Task Force
CMS CERT Compliance
Options for submitting medical records to CERT
Include barcode coversheet with all submissions.
Option to submit Electronic using esMD:
More information on esMD can be found at www.cms.gov, be sure to route medical records to the CERT Contractor at:
804-261-8100
Option to Mail:
CERT Documentation Center
Attn: CID
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
Providers mailing documentation via CD should send the password toCERTmail@empower.ai; use the CID number in the subject line of your email (no PHI).
Option to email:
Email documentation in an encrypted emailed to CERT atCERTmail@empower.ai. Password should be submitted in separate email, use the CID number in the subject line of your emails (no PHI).
Questions about medical record submissions
CERT Customer Service:
443-663-2699
Toll Free: 888-779-7477
CERTprovider@empower.ai
Questions about CERT reviews
NGS Provider Contact Center
Select “Contact Us” for phone number per state and jurisdiction
Helpful Resources
CERT Denial Finder
CERT Task Force
CMS CERT Compliance
Options for submitting medical records to CERT
Include barcode coversheet with all submissions.
Option to submit Electronic using esMD:
More information on esMD can be found at www.cms.gov, be sure to route medical records to the CERT Contractor at:
804-261-8100
Option to Mail:
CERT Documentation Center
Attn: CID
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
Providers mailing documentation via CD should send the password toCERTmail@empower.ai; use the CID number in the subject line of your email (no PHI).
Option to email:
Email documentation in an encrypted emailed to CERT atCERTmail@empower.ai. Password should be submitted in separate email, use the CID number in the subject line of your emails (no PHI).
Questions about medical record submissions
CERT Customer Service:
443-663-2699
Toll Free: 888-779-7477
CERTprovider@empower.ai
Questions about CERT reviews
NGS Provider Contact Center
Select “Contact Us” for phone number per state and jurisdiction
Helpful Resources
CERT Denial Finder
CERT Task Force
CMS CERT Compliance
Options for submitting medical records to CERT
Include barcode coversheet with all submissions.
Option to submit Electronic using esMD:
More information on esMD can be found at www.cms.gov, be sure to route medical records to the CERT Contractor at:
804-261-8100
Option to Mail:
CERT Documentation Center
Attn: CID
8701 Park Central Drive, Suite 400-A
Richmond, VA 23227
Providers mailing documentation via CD should send the password toCERTmail@empower.ai; use the CID number in the subject line of your email (no PHI).
Option to email:
Email documentation in an encrypted emailed to CERT atCERTmail@empower.ai. Password should be submitted in separate email, use the CID number in the subject line of your emails (no PHI).
Questions about medical record submissions
CERT Customer Service:
443-663-2699
Toll Free: 888-779-7477
CERTprovider@empower.ai
Questions about CERT reviews
NGS Provider Contact Center
Select “Contact Us” for phone number per state and jurisdiction