On May 18, 2015, Noridian Healthcare Solutions (Noridian) announced that it is initiating a targeted review in Montana and Washington regarding claims for DRG 470 – Major Joint Replacement or Attachment of Lower extremity without MCC. The review, which will apply to claims involving total joint arthroplasty procedures billed on or after May 11, 2015, will validate provider compliance with Medicare payment, coverage, coding, and billing rules. Facilities will be notified of selected claims during the normal Additional Documentation Request (ADR) process.
Noridian states that it is conducting this review as a result of “a trending error involving IPPS claims with DRG 470,” for services “billed with documentation that did not support the invasive procedure or failed conservative measures/treatments.” It is important to note, however, that Noridian has not adopted a local coverage determination (LCD) that sets forth detailed coverage and documentation criteria for DRG 470 cases, including expectations for conservative management prior to surgery.
In light of this announcement, AAHKS will be renewing efforts to establish predictable standards for surgeons performing total joint replacement procedures. For more information on the reviews, visit the Noridian sites for Montana and Washington.