TKA Comes Off the Inpatient-Only List What are the implications for ASCs? BY KARA NEWBURY
One of the most heavily discussed policy changes in the calendar year (CY) 2018 Hospital Outpatient Prospective Payment Sys-
tem (OPPS) was the removal of total knee arthroplasty (TKA), CPT 27447, from Medicare’s inpatient-only (IPO) list as of January 1, 2018. While TKA is not on the ASC-payable list, its removal from the inpatient-only list is a positive step toward reimbursement in the ASC setting for fee-for-service Medicare patients.
History For several years, TKA reimbursement has been a topic of discussion for the Centers for Medicare & Medicaid Ser- vices (CMS) and many organizations in the health care industry. In 2013, CMS proposed the removal of TKA from the IPO list. At that time, most comments were negative, with a few even accus- ing CMS of encouraging medical mal- practice with this proposal and, conse- quently, CMS withdrew the proposal. Since then, ASCA has been at the forefront of advocating for TKA to be removed from the IPO list. We have taken orthopedic surgeons to present to CMS medical officers on the safety and efficacy of TKA and other joint replacement surgeries. In August 2016, the Advisory Panel on Hospital Out- patient Payment (HOP) unanimously recommended that CMS remove TKA from its inpatient-only list after ASCA member Sohrab Gollogly, MD, an orthopedic surgeon in Monterey, Cal- ifornia, presented to the group. The purpose of the HOP is to advise the secretary of the US Department of Health and Human Services (HHS) and the administrator of CMS on opti- mal strategies for addressing issues related to the clinical integrity of pro-
While TKA is not on the ASC-payable list, its removal from the inpatient-only list is a positive step toward reimbursement in the ASC setting for fee-for-service Medicare patients.”
—Kara Newbury, ASCA
cedures within the hospital outpatient prospective payment system (OPPS), including “removing procedures from the inpatient list for payment under the OPPS payment system.” While the HOP’s recommendations are not bind- ing on CMS, it was helpful to have this body support the movement of this code to the outpatient setting, and the unanimous recommendation was ref- erenced in the 2018 proposed and final payment rules.
The potential removal of TKA from the IPO list did not show up again in a payment rule until the CY 2017 OPPS/ASC proposed rule, in which CMS sought public comments on the topic but did not formally propose the
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change. CMS requested stakeholder input on whether TKA met the estab- lished criteria used to identify pro- cedures to remove from the IPO list. While CMS did not make any formal policy changes in 2017, it acknowl- edged that the majority of feedback was favorable to the removal of TKA from the IPO list.
Criteria CMS Uses to Evaluate Removal from Inpatient-Only List The decision to remove TKA from the IPO list was based on CMS staff’s belief that the code can meet at least some of the following criteria: 1. Most outpatient departments are equipped to provide the services to the Medicare population.
2. The simplest procedure described by the code may be performed in most outpatient departments.
3. The procedure is related to codes that we have already removed from the IPO list.
4. A determination is made that the procedure is being performed in numerous hospitals on an outpa- tient basis.
5. A determination is made that the procedure can be appropriately and safely performed in an ASC, and it is on the list of approved ASC pro- cedures or has been proposed by us for addition to the ASC list. CMS indicated in the 2018 proposed and final rules that the agency believes TKA meets at least criteria 1, 2 and 4 above. It would be difficult to meet cri- terion 5, since CMS typically prefers to remove a code from the IPO list, make it payable in the HOPD setting for a while, and then consider its addition to the ASC-payable list. ASCA will advo- cate for criterion 5 to be removed as one of the criteria used for evaluating codes. In addition, ASCA and other stakehold-
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