How often are you faced with denied claims for joint replacements or those slow to be reimbursed because medical necessity is being reviewed or questioned?

One of the most challenging aspects of your orthopedic surgery practice these days is when you provide a service to a patient who genuinely needs a joint replacement only to find later that reimbursement has been denied.

Substantiating the need for joint replacement surgery requires detail, detail and more detail in order to avoid claim denial and keep your orthopedic revenue cycle management flowing smoothly.

The following CMS guidelines are provide to help you avoid claim denial:

Document Medical Necessity to Avoid Denial of Claims
CMS recognizes that joint replacement surgery is reserved for patients whose symptoms have not responded to other treatments. To avoid denial of claims for major joint replacement surgery, the medical records should contain enough detailed information to support the determination that major joint replacement surgery was reasonable and necessary for the patient. Progress notes consisting of only conclusive statements should be avoided.

Consequently, the medical record must specifically document a complete description of the patients’ historical and clinical findings. Examples of such information may include:


  • 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 non-surgical treatments such as:
  • Trial of medications (e.g. NSAIDs)
  • Weight loss
  • Physical therapy
  • Intra-articular injections
  • Braces, orthotics or assistive devices

[space height=”10″]

Physical Examination:

  • Deformity
  • Range of motion
  • Crepitusy
  • Effusions
  • Tenderness
  • Gait description (with/without mobility aides)

[space height=”10″]

While there are plenty of reasons an insurer might deny your claims, the most common billing errors are also the simplest and easiest to correct. Here are the top three worthy of a closer look:

1. Incorrect and/or incomplete patient identifier information (e.g., name spelled incorrectly; date of birth or soc. sec. number doesn’t match; subscriber number missing or invalid; insured group number missing or invalid)

Solution: Verify patient demographic and insurance information at EVERY visit. Ask permission to photocopy the patient’s state-issued identification (passport, drivers license, etc.) and insurance card, so that you are sure to have the proper spelling, group numbers, etc., on hand.

2. Coverage terminated

Solution: Verify insurance benefits prior to services being rendered.

3. Services non-covered/require prior authorization or pre-certification

Solution: Here again, you should contact the patient’s insurance and confirm coverage prior to services being rendered. You’ll end up with angry customers if you bill a patient for non-covered charges without making them aware that they may be responsible for the charges before their procedure.

Reducing your number of denied claims also requires the special expertise of outsourced, certified coders from Their attention to detail, exacting accuracy, quality control, legal compliance expertise, decades of industry experience and in-depth understanding of Orthopedic Surgery coding and billing produce unparalleled results and greater revenue for your practice. is the results-proven alternative for healthcare revenue cycle management, with a niche specialization in Orthopedic medical coding and billing that generates unprecedented results and builds profitable medical practices. Leveraging a history of industry wide success spanning 26 years, partners with medical practices throughout the U.S. to optimize revenue for hospital based and practice based physicians. For more information, visit

About the Author