Medicare Denying Total Knee for Not Medically Necessary

broncsrox

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We have received a couple denials from Medicare for total knee arthroplasties stating "Your Part B claim cannot be paid as the hospital's Part A claim has been denied for not medically necessary".

The hospital's coding matches ours and should have paid as far as we can see. I do recall hearing something recently about Medicare changing the protocol guidelines for total joints but I cannot remember where I heard it or read it. I have attempted to find a new policy on the CMS website but it just brings up a bunch of junk that have nothing to do with what I'm looking for.

Any thoughts or advice? We would really appreciate it!!
 

dclark7

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Have you called the hospital? Our office has found that helpful because then you can work together and appeal claims on the same basis. Since hospital biling is so different that physician billing there may be other factors involving the hospital that you are not aware of. Just a thought.
 

twosmek

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could be based on the type of admission it is--I know that if they are admitted for Mental Health it gets pretty tricky. What was the diagnosis code that you used?
 

broncsrox

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715.96 was our dx as well as what the hospital used. This is the code that has been used for as long as I've been doing this which is what leads me to believe this is a new policy that Medicare has instituted.

The hospital billing staff seems to be less than cooperative in these situations, unfortunately.

Thanks!
 

jdemar

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Have you called Medicare, could it have been an error on their part? I seem to remember getting an email related to the DX. I'd give them a call. If you & the hospital both used the same DX and it was billed correctly for the place of service (in pt?) then I would investigate further with Medicare.
 
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mitchellde

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715.96 was our dx as well as what the hospital used. This is the code that has been used for as long as I've been doing this which is what leads me to believe this is a new policy that Medicare has instituted.

The hospital billing staff seems to be less than cooperative in these situations, unfortunately.

Thanks!
Heproblem is the dx code, 715.96 is UNSPECIFIED, as to th type of osteoarthritis.
 

campy1961

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For Total Knee/Hip do not use an unspecified code. You need to be exact on why patient had to have this done. If the doctor dictated you can also use morbid obesity or obesity as a 2nd code.
 

broncsrox

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Is that new for Medicare that 715.96 is not allowed? I literally have been using 715.96 for TKA for 5 years with no problems whatsoever.
 
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