TrailBlazer Review Causes Claims Denials

The Centers for Medicare & Medicaid Services has ordered all of its contracting administrators to review Medicare Part A/B claims for completeness and documentation-related issues. TrailBlazer, the administrator for Texas, announced late last year  it would review knee and hip joint replacement surgery, among other procedures. TrailBlazer says its review showed cases where the necessary information is missing or the documentation is otherwise insufficient. This means TrailBlazer will deny payment for both Part A and B services and ask physicians subject to the review to return any amount already paid for the service.

Here's why TrailBlazer rejected claims for knee and hip joint replacements and how to make sure your claims pass the review.

In the TrailBlazer review, 94 percent of the denials were due to missing or insufficient documentation, especially documentation that substantiates the presence of end-stage joint disease and preoperative conservative measures taken.

In many cases, TrailBlazer suggests, the missing information may have been in the outpatient records of the surgeon, the primary care physician who billed services in the hospital, or other professionals such as therapists. Appropriate claim payments for inpatient hospital services require physicians and facilities to ensure proper documentation of medical necessity for the hospital care and related services. At a minimum, physicians must never consider hospital recordkeeping to be only perfunctory, TrailBlazer says. If the hospital records do not support the Part A service, payment for both the Part A and B claim is denied and recouped. Physicians and hospitals must understand that both outpatient and inpatient records should be able to stand alone to demonstrate medical necessity for related services. 

For example, if clearly documented, the following may help support payment for joint replacement care:  

  • Previous nonsurgical treatment such as physical or occupational therapy, medical management, or assistive devices;
  • Physical examination clearly documenting the progression of pain, range of motion, activity modification, or impact of activities of daily living; or
  • Preoperative diagnostic test results and interpretations showing end-stage joint disease; bone-on-bone disease, or joint deformity.

TrailBlazer says its review of claims billed with Medical Severity Diagnosis-Related Group (MS-DRG) 470 (major joint replacement or reattachment of lower extremity without major complication or comorbidities) led to denial of about 68 percent of the claims. TrailBlazer looked at the inpatient hospital claims and the associated Part B physicians' claims for services in the hospital.

Likewise, the Medicare Comprehensive Error Rate Testing (CERT) contractor reported errors on inpatient claims for knee and hip joint replacement. In each case, the CERT contractor denied the entire inpatient claim.

Contact TMA's certified coders for help with coding or billing questions


Action, Feb. 15, 2012


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