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Prepare for Changes to Medicare's Inpatient-Only Procedures

News  |  By Debbie Mackaman  
   April 01, 2018

Determine the current and future financial impacts of inpatient and outpatient TKA procedures at your healthcare organization.

This article first appeared in the March/April 2018 issue of HealthLeaders magazine.

For several years, CMS has been tossing around the idea of removing total knee arthroplasty (TKA) from its inpatient-only list (IPO) of procedures.

After much debate and input from providers, surgeons, device manufacturers, private insurance plans, and other stakeholders, CMS did just that on January 1, 2018.  

However, although CMS has removed TKA from the IPO list, this move does not categorically define the procedure as always safe to be performed on an outpatient basis.

In fact, in the CY 2018 OPPS final rule (82 Federal Register 52522–52526), CMS stated that it expects providers to use comprehensive patient selection criteria to identify appropriate outpatient candidates for the procedure, which includes patients who are in excellent health, who have limited or no comorbidities, and who will have adequate caregiver support after discharge. 

This may feel like a reprieve from a complex and burdensome healthcare regulation; however, it is actually another gray coverage and payment directive that leaves each facility in control of its own fate.

Just like with evaluation and management (E/M) code assignment in hospital outpatient departments, the data will lack consistency between facilities and development of future payments. 

Moreover, CMS is leaving it to providers to carefully develop evidence-based criteria that identify patients who are appropriate candidates for an outpatient TKA procedure, as well as exclusionary criteria that would disqualify a patient from receiving a TKA as an outpatient. The agency has no intention of developing these criteria on its own.

Keep in mind that the 2-midnight rule remains in effect, including the caveat that if a physician expects the patient to remain in the hospital for less than two midnights, he or she may still admit the patient. 

Debbie Mackaman, RHIA, CCDS, is a regulatory specialist for HCPro's Medicare Membership and Watchdog services, specializing in regulatory guidance on coverage, billing, and reimbursement. HCPro is a Simplify Compliance brand.

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