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Linda Collins Blogger

A New Audit Issue

Posted by Linda Collins | November 06, 2013

Region C has published a new audit issue that, while focused on hospital and physician claims, may have a significant impact on orthotic claims:

“Major joint replacement is reserved for patients whose symptoms have not responded to other treatments. The goal of the surgery is to relieve pain and improve or increase patient function. Medical documentation will be reviewed to determine if the major joint replacement was reasonable and necessary for the patient.”

The following information is required for the hospital and physician medical records to substantiate the medical necessity of major joint replacement:


  • Description of the pain (onset, duration, character, aggravating, and relieving factors)
  • Limitation of Activities of Daily Living (ADLs) – specify
  • Safety issues (e.g. falls)
  • Contraindications to non-surgical treatments
  • Listing and description of failed nonsurgical treatments such as:
    • Trial of medications (e.g. NSAIDs)
    • Weight loss
    • Physical therapy
    • Intra-articular injections
    • Braces, orthotics, or assistive devices

What does this mean for you?

According to CMS, major joint replacements accounted for $686.7M in improper payments during 2011. So now, the Recovery Auditors will focus their energies on whether the applicable medical records reflect the need for joint replacement, as opposed to less invasive treatment alternatives like braces and orthotics.

By publishing this guidance, RAC Region C has opened the door a crack for you to approach physicians to educate them about these requirements. Providing patients bracing solutions before moving directly to joint replacement surgery now becomes a key way that physicians and hospitals can protect themselves from Recovery Audit clawbacks in the future.

So try to meet with them. Try to educate them. You may find that for once, the Recovery Auditors have done something that indirectly helps O&P.

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