Billing and Coding: Total Knee Arthroplasty

Coverage for total knee arthroplasty (TKA/TKR) requires documented advanced knee joint disease on imaging and clinical evidence of knee pain or functional impairment (interfering with ADLs or activity/weight-bearing related pain), with prior appropriate conservative therapy when indicated. Revision, infection, malignancy, fracture, and bilateral procedures are covered when specific supporting documentation (imaging, pathology, lab reports, treatment records, and physician rationale including risk/benefit discussion for comorbid patients) is present; absent or insufficient documentation may result in denial of Part A and/or Part B services.

"Total knee arthroplasty (TKA/TKR) is covered for advanced joint disease of the knee when imaging (X-ray, MRI, or CT) documents one or more of: subchondral cysts, subchondral sclerosis, periarticula..."

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