Hip Specific:
 Hip antalgic gait due to
pain
Knee Specific:
 Crepitus on knee exam.
 Presence of joint effusion or
swelling
X-rays demonstrates at least two of the following findings:

Subchondral cysts

Joint subluxation

Subchondral sclerosis

Joint space narrowing

Periarticular osteophytes
Alternatives to Total Joint Replacement Surgery Attempted
Medication:

Documentation of 2 attempted medications:
Physical Therapy requirement is met by one of the following two
choices:

Physical therapy for a minimum of 12 weeks (provide dates)

Contraindication to physical therapy is documented in medical
record
Medical Necessity Documentation
For Joint Replacement
CLINICAL DOCUMENTATION
EXCELLENCE
[email protected]
Phone 202.660.6782
Fax 202.537.4477
Please answer CDE queries within 24 hours
Hip Specific:
 Hip antalgic gait due to
pain
Knee Specific:
 Crepitus on knee exam.
 Presence of joint effusion or
swelling
X-rays demonstrates at least two of the following findings:

Subchondral cysts

Joint subluxation

Subchondral sclerosis

Joint space narrowing

Periarticular osteophytes
Alternatives to Total Joint Replacement Surgery Attempted
Medication:

Documentation of 2 attempted medications:
Physical Therapy requirement is met by one of the following two
choices:

Physical therapy for a minimum of 12 weeks (provide dates)

Contraindication to physical therapy is documented in medical
record
Medical Necessity Documentation
For Joint Replacement
CLINICAL DOCUMENTATION
EXCELLENCE
[email protected]
Phone 202.660.6782
Fax 202.537.4477
Please answer CDE queries within 24 hours
Hip Specific:
 Hip antalgic gait due to
pain
Knee Specific:
 Crepitus on knee exam.
 Presence of joint effusion or
swelling
X-rays demonstrates at least two of the following findings:

Subchondral cysts

Joint subluxation

Subchondral sclerosis

Joint space narrowing

Periarticular osteophytes
Alternatives to Total Joint Replacement Surgery Attempted
Medication:

Documentation of 2 attempted medications:
Physical Therapy requirement is met by one of the following two
choices:

Physical therapy for a minimum of 12 weeks (provide dates)

Contraindication to physical therapy is documented in medical
record
Medical Necessity Documentation
For Joint Replacement
CLINICAL DOCUMENTATION
EXCELLENCE
[email protected]
Phone 202.660.6782
Fax 202.537.4477
Please answer CDE queries within 24 hours
Hip Specific:
 Hip antalgic gait due to
pain
Knee Specific:
 Crepitus on knee exam.
 Presence of joint effusion or
swelling
X-rays demonstrates at least two of the following findings:

Subchondral cysts

Joint subluxation

Subchondral sclerosis

Joint space narrowing

Periarticular osteophytes
Alternatives to Total Joint Replacement Surgery Attempted
Medication:

Documentation of 2 attempted medications:
Physical Therapy requirement is met by one of the following two
choices:

Physical therapy for a minimum of 12 weeks (provide dates)

Contraindication to physical therapy is documented in medical
record
Medical Necessity Documentation
For Joint Replacement
CLINICAL DOCUMENTATION
EXCELLENCE
[email protected]
Phone 202.660.6782
Fax 202.537.4477
Please answer CDE queries within 24 hours
MEDICAL NECESSITY DOCUMENTATION
FOR JOINT REPLACEMENT
Third Party payers require evidence of medical necessity for joint
replacement to be added to the patient’s hospital medical record
prior to surgery. This checklist alone does not serve as evidence of
documentation for medical necessity purposes.
Fax requested documentation no later than one week prior to surgery
to: 202-364-7639 or 202-243-5226
MEDICAL NECESSITY DOCUMENTATION
FOR JOINT REPLACEMENT
Third Party payers require evidence of medical necessity for joint
replacement to be added to the patient’s hospital medical record
prior to surgery. This checklist alone does not serve as evidence of
documentation for medical necessity purposes.
Fax requested documentation no later than one week prior to surgery
to: 202-364-7639 or 202-243-5226
MEDICAL NECESSITY DOCUMENTATION
FOR JOINT REPLACEMENT
Third Party payers require evidence of medical necessity for joint
replacement to be added to the patient’s hospital medical record
prior to surgery. This checklist alone does not serve as evidence of
documentation for medical necessity purposes.
Fax requested documentation no later than one week prior to surgery
to: 202-364-7639 or 202-243-5226
MEDICAL NECESSITY DOCUMENTATION
FOR JOINT REPLACEMENT
Third Party payers require evidence of medical necessity for joint
replacement to be added to the patient’s hospital medical record
prior to surgery. This checklist alone does not serve as evidence of
documentation for medical necessity purposes.
Fax requested documentation no later than one week prior to surgery
to: 202-364-7639 or 202-243-5226
Symptoms/Assessment
After evaluation of this patient, the following are indications for total
joint replacement surgery. This patient has all of the following
symptoms:

Preoperative joint examination showing end-stage joint disease
requiring replacement

Increasing level of pain in the hip or knee

Pain that has worsened despite conservative treatment

Pain in the hip or knee that worsens with activity

Pain in the hip or knee that worsens while bearing weight

Pain in the hip or knee that interferes with or limits activities

Passive range of motion increases pain in the hip or knee

Full range of motion is limited in the knee/hip
Symptoms/Assessment
After evaluation of this patient, the following are indications for total
joint replacement surgery. This patient has all of the following
symptoms:

Preoperative joint examination showing end-stage joint disease
requiring replacement

Increasing level of pain in the hip or knee

Pain that has worsened despite conservative treatment

Pain in the hip or knee that worsens with activity

Pain in the hip or knee that worsens while bearing weight

Pain in the hip or knee that interferes with or limits activities

Passive range of motion increases pain in the hip or knee

Full range of motion is limited in the knee/hip
Symptoms/Assessment
After evaluation of this patient, the following are indications for total
joint replacement surgery. This patient has all of the following
symptoms:

Preoperative joint examination showing end-stage joint disease
requiring replacement

Increasing level of pain in the hip or knee

Pain that has worsened despite conservative treatment

Pain in the hip or knee that worsens with activity

Pain in the hip or knee that worsens while bearing weight

Pain in the hip or knee that interferes with or limits activities

Passive range of motion increases pain in the hip or knee

Full range of motion is limited in the knee/hip
Symptoms/Assessment
After evaluation of this patient, the following are indications for total
joint replacement surgery. This patient has all of the following
symptoms:

Preoperative joint examination showing end-stage joint disease
requiring replacement

Increasing level of pain in the hip or knee

Pain that has worsened despite conservative treatment

Pain in the hip or knee that worsens with activity

Pain in the hip or knee that worsens while bearing weight

Pain in the hip or knee that interferes with or limits activities

Passive range of motion increases pain in the hip or knee

Full range of motion is limited in the knee/hip