Total joint replacement has become one of the clearest growth engines in ambulatory surgery. Medicare is clearing the last regulatory barriers, facility rates for joints are rising and the largest ASC operators report double-digit joint growth. Surgeon pay cuts, a new mandatory hospital bundle and a shrinking pool of ideal outpatient candidates complicate the picture. Here’s what is shaping the service line heading into 2027.
1. Medicare’s inpatient-only list will disappear in 2028.
CMS’ 2027 OPPS/ASC proposed rule, released July 2, would remove 637 procedures from the inpatient-only list, with the remaining 801 more complex procedures scheduled to come off in 2028. That would complete a three-year phaseout.
Total knee arthroplasty came off the list in 2018 and total hip in 2020, so the 2027 rule finishes a shift nearly a decade in the making. Where a joint replacement happens is becoming a clinical and financial decision rather than a regulatory one.
2. The ASC covered procedures list keeps growing.
The 2027 proposed rule would add 618 codes to the ASC-covered procedures list.
It follows a record 2026. CMS added 168 orthopedic codes to the list for 2026, opening the ASC to revision total hip arthroplasty, revision total knee arthroplasty and partial shoulder revisions for the first time.
3. Facility rates for joints are trending up.
The proposed rule projects a 2.4% effective ASC update overall, but orthopedic, device-intensive codes outperform it.
Proposed changes from 2026 to 2027 ASC rates:
- Total shoulder replacement: almost $1,000 more
- Total hip replacement: nearly $500 more
- Total knee replacement: nearly $400 more
4. Surgeon pay is moving the other way.
The 2027 Medicare physician fee schedule proposal cuts the conversion factor 1.68% for non-APM participants, to $32.8409. Specialty-level estimates suggest orthopedic surgery could fall another 7% beyond that, with some joint replacement procedures facing cuts up to 20%.
The American Academy of Orthopaedic Surgeons opposed the proposed RVU reductions of more than 20% for total hip, knee and shoulder arthroplasty in its Sept. 14 comment letter. For ASC leaders, that pressure lands on physician partners’ economics and alignment.
5. CJR-X is final, and ASCs will feel it indirectly.
CMS finalized the CJR-X bundle July 31 in the fiscal 2027 IPPS rule. All acute care hospitals paid under the IPPS must participate starting Jan. 1, 2028, three months later than proposed. Episodes run from surgery through 90 days of recovery.
ASCs are not formal participants. But CMS intends to price low-acuity lower extremity joint episodes site-neutrally, with the same target price whether the case happens in a hospital outpatient department or an ASC. Expect hospitals to scrutinize where their surgeons operate and to seek tighter partnerships with ASCs.
6. The base is large and growing.
More than 600 ASCs perform total joint replacements as of 2026. ASCs perform more than 42,000 total knee and 24,000 total hip replacements annually.
The largest operators report strong momentum:
- Surgery Partners: Total joints in its ASCs grew 14.6% year over year in Q1 2026.
- Tenet’s USPI: Same-facility revenue rose 5.3% year over year, led by double-digit total joint volume growth.
7. Robotics is the recruiting tool.
USPI added roughly 150 robotic surgery programs in its ASCs in Q1 2026 alone. Surgery Partners now runs 73 surgical robots and adds double-digit units each year; its executives call robotics the primary unlock for physician adoption of higher-acuity ASC cases. For centers building a joint line, the robot increasingly shapes which surgeons will bring cases.
8. The easiest patients may already have moved.
Not every forecast is bullish. Advisory firm Weaver argues the younger, healthier, lower-BMI patients best suited to outpatient joints have largely been captured, which may slow further migration. It also notes that some joint surgeons are now health system employees, keeping their volume in the hospital.
Growth from here likely depends on patient selection protocols, care coordination for higher-acuity patients and physician alignment, not just regulatory permission.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
