ers have argued that criterion 3 is met with codes such as Unicompartmental Knee Arthroplasty, CPT 27446, which is currently on the ASC-payable list. CMS acknowledged receiving


comments but did not respond to con- firm acceptance of our position. While the majority of comments were positive, several commenters did oppose the removal of TKA from the IPO list, including national and state- level hospital associations and hospi- tal systems. Some of these commenters expressed concerns that TKA was not clinically appropriate for the outpatient setting. These commenters stated that the “TKA procedure is invasive and Medicare beneficiaries are more likely to have comorbidities that could make pain more difficult to control. The com- menters also stated that, because of these comorbidities, Medicare beneficiaries will face greater complications, recov- ery times, and rehabilitation needs than non-Medicare populations to recover from TKA procedures.” CMS did not agree with these commenters and indi- cated that it will rely on the medical judgment of surgeons to appropriately identify patients that are suitable for outpatient TKA procedures. CMS also reiterated that removal from the IPO list does not mean procedures must be per- formed on an outpatient basis and indi- cated that it expects to continue to see substantial inpatient TKA volume.

Consideration of Total Hip Arthroplasty (THA) and Partial Hip Arthroplasty (PHA) In the CY 2018 OPPS/ASC proposed rule, CMS also sought responses to whether the agency should con- sider removing THA and PHA, the procedures described by CPT codes 27125 and 27130, from the IPO list. It requested comments on the same cri- teria used above for TKA procedures. While CMS did not move either of these codes from the IPO list, it did state it would take all feedback into consider- ation during future rulemaking.

Consideration of Joint Replacement Codes for ASC-Payable List As CMS discussed in the CY 2009 OPPS/ASC final rule with comment period, the agency will annually eval- uate the ASC list of covered surgical procedures and review the procedures that are being proposed for removal from the OPPS IPO list for possible inclusion on the ASC list of covered surgical procedures. As part of this review, CMS must determine if these codes fall under any of the ASC list exclusionary criteria.

ASC List Exclusionary Criteria In the 2018 proposed rule, CMS requested public comments on whether TKA, THA and PHA meet the crite- ria for addition to the ASC-payable list. The current exclusionary criteria, found at 42 CFR §416.166, are: ■■

Poses a significant safety risk to the beneficiary;

■■ Typically requires active medical

monitoring and care past midnight; ■■ Directly involves major blood vessels; ■■


Requires major or prolonged inva- sion of body cavities; Generally results in blood loss;

■■ Emergent in nature;

■■ ■■


Life-threatening in nature;

Commonly requires systemic throm- bolytic therapy; or

Can only be reported using an unlisted surgical procedure code CMS determined it should continue

to exclude TKA from the ASC-payable list because the agency’s “understand- ing is that these procedures typically require more than 24 hours of active medical care following the procedure.” ASCA will look to our membership to provide length of stay data to help sup- port our advocacy efforts on this front. While fee-for-service Medicare cases will not be reimbursed in the ASC setting in 2018, CMS did indicate that it appreciated the feedback received and “will take the suggestions and rec- ommendations into consideration for future rulemaking.” The removal of total knee arthroplasty from the inpa- tient-only list is an important step to seeing this procedure covered in the ASC setting in the future. ASCA will continue to work with CMS to educate its staff on the safety and efficacy of these procedures when performed in the ASC setting.


Kara Newbury is ASCA’s regulatory counsel. Write her at


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