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Total Hip Replacement - Medco

This document provides guidance for processing claims under the PM-JAY scheme for four total hip replacement procedures: cemented, cementless, hybrid, and revision. It outlines the covered procedures, package prices, average length of stay, doctor qualifications, and empanelment criteria. The document also specifies mandatory documents that must be submitted for pre-authorization and reimbursement claims, including clinical notes, x-rays, indoor papers, photographs, invoices, and discharge summaries. It describes key clinical indicators for the procedures and states that the transaction management system will include checks to confirm implants are seen on post-op x-rays and pre-op x-rays for revision procedures.

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Tamal Deb Barma
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0% found this document useful (0 votes)
165 views3 pages

Total Hip Replacement - Medco

This document provides guidance for processing claims under the PM-JAY scheme for four total hip replacement procedures: cemented, cementless, hybrid, and revision. It outlines the covered procedures, package prices, average length of stay, doctor qualifications, and empanelment criteria. The document also specifies mandatory documents that must be submitted for pre-authorization and reimbursement claims, including clinical notes, x-rays, indoor papers, photographs, invoices, and discharge summaries. It describes key clinical indicators for the procedures and states that the transaction management system will include checks to confirm implants are seen on post-op x-rays and pre-op x-rays for revision procedures.

Uploaded by

Tamal Deb Barma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Guidance document for processing PM-JAY packages

Total Hip Replacement


Procedures covered/ procedure count: 4
Specialty: Orthopedics

Package name Procedure name HBP 1.0 code HBP 2.0 code Package price*
Total Hip Replacement Cemented S500091 SB038A 35000

Total Hip Replacement Cementless S500092 SB038B 37000

Total Hip Replacement Hybrid S500093 SB038C 32000


Total Hip Replacement Revision - Total Hip New package SB038D 40000
Replacement
*Implant price extra
ALOS: 5-7 days
Minimum qualification of the treating doctor:
Essential: Diploma in Orthopedics with 10 years of experience
Desirable: MS/DNB in Orthopedics
Special empanelment criteria/linkage to empanelment module:
Disclaimer:
For monitoring and administering the claim management process of Total Hip Replacement –
Cemented, Total Hip Replacement – Cementless, Total Hip Replacement – Hybrid and Total Hip
Replacement – Revision, NHA shall be following these guidelines. This document has been prepared
for guidance of PROCESSING TEAM and TRANSACTION MANAGEMENT SYSTEM of AB PM-JAY for the
claims of procedures mentioned above. The hospitals can also refer to this document so that they have
the insight on how the claims will be processed. However, this document doesn’t provide any guidance
on clinical and therapeutic management of patient. In that respect the hospitals and physicians may
refer to any other relevant material as per the extant professional norms.

PART I: Guidelines for Clinicians and Healthcare Providers


1.1 Objective:
The purpose of this section is to act as a guidance & a clinical decision support tool for the
clinicians in deciding the line of treatment, plan clinical management of patient and decide
referral of cases to the appropriate level of care (as required) for treatment of patients under
PMJAY and selection of corresponding Health Benefit Package.
It will also serve as a tool for hospitals to determine and submit the mandatory documents
required for claiming reimbursement of health benefit package under PMJAY.
1.2 Clinical key pointers:

National Health Authority Version 1.1 Dated June 2020


• Osteoarthritis
• Rheumatoid arthritis
• Osteonecrosis
• Pain Persists, despite pain medication
• Pain Worsens with walking, even with a cane or walker
• Pain Interferes with patient’s sleep
• Affects the patient’s ability to go up or down stairs
• Makes it difficult to rise from a seated position

1.3 Mandatory documents- For healthcare providers


Following documents should be uploaded by the concerned hospital staff at the time of pre-
authorization and claims submission:

Mandatory document Total Hip Total Hip Total Hip Total Hip
Replacement - Replacement - Replacement - Replacement -
Cemented Cementless Hybrid Revision
i. At the time of Pre-
authorisation
a. Clinical notes with Yes Yes Yes Yes
indication for surgery
b. X-ray / CT of Hip labelled Yes Yes Yes Yes
with patient ID, date
and side (Left/ Right)
c. Pre-op X – ray of the No No No Yes
affected hip shows
implant
ii. At the time of claim
submission
a. Indoor case papers Yes Yes Yes Yes
b. Post op clinical Yes Yes Yes Yes
photograph
c. Post op X-ray showing Yes Yes Yes Yes
the implant. The X-ray is
labelled with patient ID,
date and side (Left/
Right)
d. Invoice / bar code of Yes Yes Yes Yes
implant
e. Detailed OT note Yes Yes Yes Yes

National Health Authority Version 1.1 Dated June 2020


f. Discharge Summary Yes Yes Yes Yes

PART II: GUIDELINES FOR PROCESSING TEAM


PART III: GUIDELINES FOR TRANSACTION MANAGEMENT SYSTEM (TMS)
3.1 Objective: To enable setting up of cross check mechanisms/rule engines within the IT
platform (TMS) to ensure compliance with STGs and to prevent fraud / abuse of the Health
Benefit Package.

3.2 Below mentioned are the scenarios where a provision would be built in TMS for pop-
ups:
I. Does the Post-op X- ray / CT of hip show the presence of implant? – Yes
II. If the patient is undergoing Revision hip replacement, does the pre-op X-ray/ CT of hip
show the presence of implant? - Yes
Till the time the functionality is being developed, the processing doctors shall check the above
manually.
__________________________________________________________________________

National Health Authority Version 1.1 Dated June 2020

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