LCD ID Number: L36007 Status: A-Approved
LCD Title: Lower Extremity Major Joint Replacement (Hip and Knee)
Geographic Jurisdiction: Delaware Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
Revision Effective Date:
Revision End Date:
CMS National Coverage Policy:
This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for lower extremity major joint replacement (hip and knee). Federal statute and subsequent Medicare regulations are lengthy and they are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for lower extremity major joint replacement (hip and knee) and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 40 – Surgeons and Global Surgery
- CMS IOM Publication 100-08, Program Integrity Manual
- Chapter 3, Section 184.108.40.206 – Signature Requirements
- Chapter 6, Section, 6.5.2 - Conducting Patient Status Reviews of Claims for Medicare Part A Payment for Inpatient Hospital Admissions
- Chapter 13, Section 13.5.4 - Reasonable and Necessary Provisions in an LCD
- MLN Matters Number: SE1236 Documenting Medical Necessity of Major Joint Replacement (Hip and Knees) www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1236.pdf
- MLN Booklet Major Joint Replacement (Hip or Knee) ICN 909065 May 2017. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/jointreplacement-ICN909065.pdf
Social Security Act (Title XVIII) Standard References:
- Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
- Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
- Title XVIII of the Social Security Act, Section 1833 (e). This section states that no payment shall be made to any provider for any claims that lack the necessary information to process the claim.
Federal Register References:
- Title 21 Code of Federal Regulations (CFR), Chapter I, Subchapter H, Part 888 - Orthopedic Devices
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