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CMS reaches final decision on covering knee arthroscopy for OA
In some cases documentation may be required to support why the procedure was done.
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A final National Coverage Decision has been issued by the Centers for Medicare and Medicaid regarding performing knee arthroscopy for osteoarthritis. It disallows coverage for arthroscopic lavage alone, arthroscopic debridement for pain alone, and arthroscopic treatment of patients with severe arthritis, the main conditions for which the procedure is not typically indicated.
The National Coverage Decision (NCD) issued June 10, however, leaves at the local contractor’s discretion the use of arthroscopic debridement and/or lavage to treat patients who have symptoms besides pain, including mechanical symptoms like locking or snapping, normal joint alignment and mild or early degenerative osteoarthritis (OA).
The NCD constitutes changes to national coverage determinations previously issued by Medicare. It was effective June 11 with an implementation date of July 11, according to CMS.
AAOS concurs
The coverage decision reflects what the American Academy of Orthopaedic Surgeons (AAOS) and other musculoskeletal societies advocated while working with Medicare.
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“All in all we’re pretty happy with it because it’s in line with what was advocated,” Dan Sung, AAOS policy analyst, told Orthopedics Today. Sung was involved in ongoing communications between the AAOS and CMS.
Academy officials welcomed the inclusion of specifics regarding those arthroscopic procedures that might be covered under local contractor discretion in the NCD, they said in a recent email communication to AAOS members. These indications were not clarified in the decision memo that CMS initially issued July 3, 2003, they said.
Alan H. Morris, MD, of St. Louis, told Orthopedics Today the three indications for knee arthroscopy that will no longer be covered by CMS have “been the teaching for arthroscopy in OA all along for years. Anybody who does arthroscopy has said that. So … we had no issues with their statements here.”
Appropriate OA classification?
But, the one AAOS recommendation that appeared to have been glossed over by CMS this time around was substituting a radiographic OA classification, such as the Kellgren-Lawrence scale, for the Outerbridge classification that CMS proposed be used to determine OA severity, he said. The NCD, as well as last year’s national coverage analysis, defined severe OA using Outerbridge scale, grades III and IV.
AAOS officials and other musculoskeletal organizations
working on the NCD determined that a radiographic scale was better than the
Outerbridge classification since the latter is arthroscopy-based and requires
patients to first undergo arthroscopy.
That aside, what should affect orthopedic surgeons’ practices most from the NCD are those circumstances when arthroscopies are performed at local contractor discretion, said Morris, a member of Orthopedics Today's Health Policy Section on the editorial board. As stated in the Medicare National Coverage Determinations Manual, section 150.9, “Medicare contractors may require submission of one or all of the following documents to define the patient’s knee condition: operative notes, report of standing x-rays or arthroscopy results.”
“That’s the indication to us, as physicians, that if this is denied be prepared to have your operative reports and have your documentation. There’s nothing wrong with that … if we’re doing this surgery appropriately this should be a covered service,” Morris said.
Chief medical editor of Orthopedics Today Douglas W. Jackson, MD, said in an interview that the noncoverage decision reached by CMS “is a portend of how payers for health care may use one or more scientifically controlled studies or evidence-based medicine to establish practice guidelines. In this case it was following input from and discussions with the orthopedic community. That may happen to varying degrees in the future by other third-party payers. This experience should cause scientific orthopedic groups to be proactive in analyzing other long-standing and new procedures for their documentable therapeutic benefits.”
According to Sung, the AAOS currently foresees no other issues in the near future like this where they would need to again deal so closely with CMS to determine coverage parameters.
For more information:
- A copy of the coverage decision can be found on the Web at: http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=150.9&ncd_version=1&show=all