Clinical Orthopaedics and Related Research®

, Volume 474, Issue 11, pp 2544–2544

Letter to the Editor: Editorial: How the Words We Use Affect the Care We Deliver

Letter to the Editor

DOI: 10.1007/s11999-016-5046-2

Cite this article as:
Kagan, A. Clin Orthop Relat Res (2016) 474: 2544. doi:10.1007/s11999-016-5046-2
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To the Editor,

I read your editorial [2] with interest and appreciation. I have certainly been guilty of claiming that the patient has “failed conservative care.” Stu (my physician assistant) and I began to wonder where this verbiage came from and why we were using it. Stu mentioned that often the words we select have been chosen to match the requirements from insurance providers to facilitate the preapproval process. I asked our insurance billing supervisor to research current Florida Medicare billing guidelines for TKA. While researching the Medicare fiscal intermediary’s Local Coverage Determinations (#L33618) [1], she found the section below (emphasis mine):

“Coverage Indications, Limitations, and/or Medical Necessity

. . . Other findings include chronic knee inflammation or swelling not relieved by rest, knee stiffness, lack of pain relief after taking non-steroidal anti-inflammatory medications and failure to achieve symptom improvement with other conservative therapies such as steroid injections and physical therapy.” [1].

Further down, she found (emphasis mine):

“Indications

Total knee replacement surgery will be considered medically necessary when one or more of the following criteria are met:

*See Documentation Requirements section for additional information

Total knee arthroplasty (TKA)
  • Failure of a previous osteotomy; or

  • Distal femur fracture; or

  • Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; or

  • Failure of previous unicompartmental knee replacement; or . . .” [1].

Maybe it is not completely our fault, but we should continue to strive for better communication! Keep up the good work!

Copyright information

© The Association of Bone and Joint Surgeons® 2016

Authors and Affiliations

  1. 1.Department of Surgery—OrthopaedicsLee Memorial Health SystemFort MyersUSA