Local coverage determinations for spinal fusion and total joint replacements explained

Issue: June 2012

ByJason S. Mazza, MSc, OA-C, CSA, SA-C, OTC, CCRC

One of the main roles of allied health providers and physician extenders is to provide clinical support to the practicing orthopedic surgeon. Assisting with clinical examinations, documenting of findings and providing patient education by the physician extender helps the surgeon see a greater volume of patients while providing quality care. Models of clinical care are constantly changing as is practice reimbursement.

In 2010, President Obama announced three specific goals for cutting Medicare spending by 2012. These goals included:

reducing payment errors;
cutting Medicare fee-for-service error rate in half; and
recovering more than $2 billion in improper payments.

In response, the Centers for Medicare & Medicaid Services (CMS) announced a plan to achieve each goal. The Recovery Audit Contractor was created by Medicare in 2003 and serves to review, audit and scrutinize Medicare payments in the divided geographic regions of the United States. In mid-2011, a local coverage determination policy (LCD) for spinal fusion and total joint replacements was developed for Florida. The goal was to minimize improper Medicare payments through a series of claim reviews. All claims were to be reviewed retrospectively. Initially, the Medicare Administrative Contractors (MAC) began auditing 100% of all Medicare Part A claims starting in January 2012, but has since reduced this number. Under the audit, if payment for a claim is denied for the primary procedure (lumbar fusion, total hip or total knee replacement), a subsequent post-payment audit of the physician service claims also can be expected to fail for medical necessity. In essence, the audit has or will force many practitioners to change the way they practice orthopedics.

Criteria

Local coverage determinations for lumbar fusion for degenerative conditions and total joint replacement (lower extremity) have been published by the MAC provider, First Coast Service Options Inc. We are no longer able to initially offer surgery to a patient who has bone-on-bone joint line changes to his or her knee and has had a cortisone injection or perhaps an anti-inflammatory medication. Certain criteria must now be met and well-documented before a patient can be admitted for elective surgery that falls under these diagnosis related groups. The actual criteria are too long to list here for lumbar fusion and total joint replacements, but can be full reviewed on the following websites:

Lumbar fusion for degenerative condition — http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L32076#LCD; and
Total knee replacement and total hip replacement — http://medicare.fcso.com/Fee_lookup/LCDDisplay.asp?id=L32081.

A 3-month history of conservative care is required, which includes the use of non-steroidal anti-inflammatory medications (or documentation of contraindications), activity modification, weight reduction when indicated, supervised physical therapy, smoking cessation, and cognitive or behavioral therapy when indicated. Additionally, specific criteria must be met for a lumbar fusion based on imaging findings and, in some cases, clinical examination. The LCD for total joint replacements, including both hip and knee replacements, follows similar treatment guidelines as previously documented for lumbar fusion surgery. Therapeutic injections into the knee and use of an assistive device are also included as non-surgical care. The policy is also specific with radiographic findings or other imaging studies when X-rays cannot be obtained.

Data and documentation

As many practices have shifted from traditional pen-and-paper to electronic medical records, the collection of the required information becomes less onerous. However, there are still several challenges for the practicing surgeon and allied health provider. First, it is important that providers who work with a surgeon to be are aware of the specific indications that must be met for a patient to have surgery. In cases where the allied health provider practices in an autonomous or semi-automous role to the surgeon, a clear management plan for the patient should be derived from the initial visit. If the history, examination and imaging studies suggest that the patient will most likely require surgical management, then a protocol or stepwise process should be dictated for subsequent visits to achieve all necessary criteria and surgical indications. Patients also need to be educated about the criteria. Many patients do not know they cannot have an injection or other treatment and move on to surgery if they do not improve during a certain timeframe. As the patient’s treatment plan progresses, a comprehensive summary of all office notes will need to be performed.

Audits are being performed retrospectively, and it can be easy, in some cases to overlook one specific non-surgical treatment in the documentation. This may lead to non-payment to the surgeon and the hospital. The allied health provider can play a key role in documenting the entire treatment course, including treatment dates, response to treatment and the specific dates of patient education and counseling. We cannot rely on the primary care physician or other outside provider to discuss the importance of smoking cessation or weight reduction. This needs to be a standard for all patients we see. Our admitting history and physical for the hospital needs to be dictated clearly to show that medical necessity for the consented procedure was obtained.

Patient care

The process of improving documentation and ensuring that all criteria were met adds an extended component of time for each patient. To some, it is an onerous task of more to do to get paid less, or not at all, in some cases. To others, the process can help redefine how to provide more efficient patient care and improve documentation for office-based service claims. Some patients will benefit and realize the positive health benefits from exercise, weight and tobacco counseling as these are “required” components of achieving medical necessity. From our early experience, the LCDs have several gray areas and limit some patients from getting the needed care and also may constrain some surgeons’ ability to provide appropriate care. It is expected that CMS will go beyond the DRGs and implement the policies for other procedures in more geographic regions.

The allied health provider who works with orthopedic surgeons in a clinical setting will play a key role in helping to assimilate the necessary data and documentation for proving medical necessity. This will provide a large time savings to the surgeon and, in many cases, will help provide more efficient patient care. A detailed understanding of the requirements is paramount.

For more information:

Jason Mazza, MSc, OPA-C, CSA, SA-C, OTC, CCRC, is immediate past-president of American Society of Orthopaedic Physician’s Assistants. He can be reached at 727-743-5636; email: jasonm@boneshurt.com.
Disclosure: Mazza has no relevant financial disclosures.