Joint Replacement Documentation in the Wake of the Comprehensive Care for Joint Replacement (CJR) Final Rule

Ortho ICD-10-PCS can be a daunting clinical area for both coding professionals and clinical documentation specialists. There have been seemingly endless ICD-10 Coding Clinics over the past 3 years intended to update, clarify and correct PCS code assignments and these have caused a feeling of trying to tread water in a mud pit. Now, add to that the Comprehensive Care for Joint Replacement (CJR) Final Rule which took effect on April 1, 2016.

The CJR contributes to the quicksand effect in the already murky area of Quality Measures and Reporting Requirements set by CMS, making it more important than ever for CDI and Coding to work together to understand the consequences of how specific documentation leads to the correct PCS code assignment and therefore the correct MS-DRG.

Exactly what is the Comprehensive Care for Joint Replacement (CJR) Final Rule? It is a payment model that holds hospitals accountable for the quality and total Medicare cost for lower extremity joint replacement (LEJR) procedures and recovery which includes all hip and knee replacements-the most common inpatient surgeries for Medicare beneficiaries.

Included in the model are all lower extremity joint arthroplasty procedures within DRGs 469 and 470.These include elective hip and knee arthroplasty procedures (total or partial) caused by osteoarthritis or similar conditions, but also include ankle arthroplasty, as well as arthroplasty for fracture repair such as hip hemiarthroplasty or total hip arthroplasty for hip fracture.

Under this model hospitals and post-acute care providers are held jointly accountable for all Medicare Part A and B spending occurring during what is referred to as an “Episode”. An “episode of care” begins with the admission of a Medicare beneficiary for a service that is ultimately assigned to MS-DRG 469 or 470 and ends 90 days post-discharge.

Although providers (including SNF’s) and suppliers will still be paid under the same fee-for-service payment system rates for services provided throughout each year they will be eligible for an additional reconciliation payment (or pay back)after completion of a performance year based on quality performance, post-episode spending and policies to limit hospital financial responsibility.

The CJR model bases the payment or pay back amounts on a composite score from 3 areas:

  1. 50%=Hospital-Level Risk-Standardized Complication Rate (RSCR) following elective primary THA and/or TKA (National Quality Forum [NQF] measure #1550)
  2. 40%= Hospital Consumer Assessment of Healthcare Provider and Systems (HCAHPS) Survey measure (all, not just TJR’s)
  3. 10%= Voluntary THA/TKA Patient-Reported Outcomes (PRO) with focus on pain management.

Of note, CMS also plans to post CJR hospitals’ quality performance scores on their Hospital Compare website. Click here to read the entire CJR Model.

So how does all of this affect documentation, CDI and coding? First, the CJR model only applies to MS-DRG 469 (Major joint replacement or reattachment of lower extremity with MCC) or MS-DRG 470 (Major joint replacement or reattachment of lower extremity without MCC). Only straightforward replacement (many times referred to as arthroplasty or hemiarthroplasty) of a knee or hip joint are subject to the quality reporting necessary and the possible additional payment or pay back of fees.

Secondly, the documentation must be specific with regard to possible complications that are or could be linked to the surgery. CDI & Coding need to be diligent in clarifying any diagnoses that may, or more importantly, may NOT be linked to the surgery and any readmission related to possible complications.

The following outcomes (one or more) are considered complications in the RSCR measure:

  • Acute myocardial infarction (AMI)
  • Pneumonia, sepsis/septicemia/shock within 7 days from admission
  • Death, surgical site bleeding, pulmonary embolism within 30 days of admission
  • Mechanical complications of the joint, periprosthetic joint infection, wound infection within 90 days of admission

Note that Revisions or complete Removal with complete Replacement of a knee or hip joint prosthesis (DRGs 466, 467 and 468) would not be subject to the CJR payment model. However, if it is a readmission possibly linked to a replacement surgery that occurred WITHIN THE PRIOR 90 DAYS it may be reported as part of Measure 1 (NQF RSCR) for that episode. Therefore the same diligence is necessary to clarify any complications and their cause or linkage to any previous replacement surgery.

Equally important, when coding an Ortho surgery to “replace” the hardware from a previous knee or hip replacement surgery due to a mechanical problem it is extremely important to code both the Removal of the old hardware and the Replacement of the new hardware to insure the correct DRG assignment to 466-468. If only the replacement is coded then it will be assigned to one of the DRGs in the CJR model.

In the end, complete and accurate documentation which in turn will lead to the correct coding of joint replacement surgeries, whether elective, revision or due to a complication is at the forefront with the advent of the CJR payment model.

Virginia Bailey RN, CCDS
CDI Education & Training Consultant
MedPartners, Med Partners University Division


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