'An unprecedented amount of confusion' — Orthopedic society criticizes CMS for TKA final rule

The American Association of Hip and Knee Surgeons recently issued a position statement on the 2018 Medicare Outpatient Prospective Payment System rule that removed total knee arthroplasty from Medicare's inpatient-only list.

The society noted while CMS removed TKA from the inpatient-only list, the agency did not allow the procedure to be performed in freestanding ASCs, which denotes a desire to move slowly concerning TKA. The society believes CMS expected a large majority of TKA procedures would continue to be performed in an inpatient setting.

"Unfortunately, the unintended consequence of this change has been an unprecedented amount of confusion on the part of a variety of stakeholders regarding how to interpret this new rule. Hospitals, surgeons, and payers are interpreting the rule from different perspectives and as such are each coming to very different conclusions," the society said in a statement.

Confusion is apparent when billing for the procedure. A reinterpretation of the two-midnight rule is creating confusion because CMS treats some cases spanning less than two midnights as inpatient procedures, if a patient's record contains documentation of need. Traditionally, a case is inpatient if a patient stays for more than two nights.

The society believes the current rule is being misinterpreted by parties requiring documentation of medical need. Documentation of medical need is not required in all cases, but in select cases.

The society also chastised pressure placed on physicians to make outpatient the default designation for a patient prior to surgery, especially in cases where one midnight for recovery is sufficient, but the patient is "clearly not [an] acceptable outpatient candidate."

AAHKS issued three pillars of guidance for its members:

1. Expect the vast majority of patients to be treated, by default, as inpatient. The group argues, "The physiology of patients did not change, nor did the standard of care, from December 2017 to January 2018."

2. Hospitals, physicians and payers should agree the burden of proof is on the physician to state what criteria are present that suggest inpatient resources should not be utilized.

3. AAHKS encourages its members to use outpatient designation, when doing so will not increase adverse event risk.

"to only utilize an outpatient designation for a patient when doing so does not pose the risk of making the occurrence of, or failure to detect, such an adverse event more likely."

To read the group's full statement, click here.

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