Billing and Coding: Total Joint Arthroplasty

This policy provides billing, coding, and documentation guidance for total knee and hip arthroplasty (TKA/THA) that supplements the LCD: coverage requires documentation of advanced joint disease with specified radiographic findings, documented functional impairment affecting ADLs, and evidence of unsuccessful conservative management unless clearly inappropriate. Medical records must include standard hospital documentation (H&P, discharge summary, progress notes, operative report), supporting tests/reports (imaging, labs/pathology for infection), and the referring physician NPI when required; lacking adequate documentation may result in claim return or denial. Devices used should comply with FDA Class II/III requirements and services exceeding established parameters may be subject to medical necessity review.

"Total knee arthroplasty (TKA) or total hip arthroplasty (THA) is indicated for advanced joint disease when X-ray or MRI demonstrates subchondral cysts, subchondral sclerosis, periarticular osteophy..."