Documentation of surgical decision-making may reduce Medicare audit requests
Key takeaways:
- Among the 210 TJA cases audited, 2.8% were denied payment.
- Creation of a template of note for decision to pursue surgery may reduce Medicare audit requests of TJA cases.
SAN DIEGO — Standardized documentation of surgical decision-making and preoperative surgical care may reduce Medicare audit requests for total joint arthroplasty cases, according to results.
“CMS hires [Recovery Audit Contractors] audit companies in order to claw back money. It cost us around $75,000 for the cases that were rejected. That is money for our hospital margins that is greatly necessary,” Richard Iorio, MD, vice chair of clinical effectiveness at Brigham and Women’s Hospital, told Healio. “In order to avoid the audits, which are time-consuming and require a great deal of resources, we are able to avoid them because we provide the documentation in advance so [the auditors] do not need to go looking for it with an audit process.”
Iorio, Audrey N. Kobayashi, MD, PhD, and colleagues identified 210 Medicare TJA cases audited in six separate inquiries from June 2022 to June 2023, of which 138 were from an academic medical center and 72 were from a community-affiliated hospital.
“Two hundred ten cases were audited, [and] six were denied payment, which was 2.8%,” Kobayashi, a clinical fellow in orthopedic surgery at Massachusetts General Hospital, said in her presentation at the American Academy of Orthopaedic Surgeons Annual Meeting. “After the initial review of 46 cases with six denials, all subsequent audits were resolved successfully.”
According to Kobayashi, a template of note for the decision to pursue surgery was used after the initial audits. This template of note included “CMS criteria for exhausting conservative care, and we include these criteria in our preoperative history and physical,” she said.
After implementation of the template of note, Kobayashi said they had success in reversing all audits after the initial 46 cases.
“During the first audit, 46 cases were denied. All of those were subsequently appealed, and six of those appeals were upheld,” Kobayashi said. “This translates to roughly $76,000 lost in revenue, which was about on average $13,000 per case.”
Richard Iorio, MD, of Brigham and Women’s Hospital, can be reached at riorio@bwh.harvard.edu.
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Olsen AS, et al. Paper 71. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 10-14, 2025; San Diego.