Knowledge Base Article

“Inpatient only” services are generally, but now always, surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged.

• Source: Medicare Claims Processing Manual, Chapter 4 – Part B Hospital

CMS released the Calendar Year (CY) 2018 OPPS/ASC Final Rule last Wednesday November 1st. For CY 2018 CMS proposed two changes to the Inpatient Only (IPO) List and had one request for solicitation. This article provides highlights from section IX. Procedures That Will Be Paid Only as Inpatient Procedures section of the Final Rule.

Total Knee Arthroplasty Public Comments

Many commenters believed that appropriately selected patients who are in excellent health, have no or limited medical comorbidities, and have sufficient caregiver support could be successful candidates for outpatient TKA. Following are TKA topic specific comments and how CMS responded.

Patient Selection for Outpatient TKA

Commenters

• Commenters supported the proposal, with “caveats regarding patient safety, including requests that CMS develop, with input from stakeholders, patient selection criteria and risk stratification protocols for TKA to be performed in an outpatient setting.”
• Two orthopedic specialty societies noted their organizations are in the process of developing these patient selection and protocol tools.

CMS Responds

• CMS believes that surgeons, clinical staff, and medical specialty societies performing outpatient TKA procedures possess the specialized clinical knowledge and experience are most suited to create patient selection guidelines. As such, they do not expect to create or endorse specific guidelines or content.

Determining Appropriate Site for Surgery

Commenters

• There were requests that “CMS explicitly state that the surgeon is the final arbiter of the appropriate site for the surgical procedure, that CMS provide an incentive for outpatient and ambulatory settings performing TKA, PHA, and THA to be a part of a registry such as the American Joint Replacement Registry, and CMS confirm that all surgeons will continue to have the option to select the appropriate setting (inpatient or outpatient) for the procedure.”

CMS Responds

• CMS indicates they “continue to believe that the decision regarding the most appropriate care setting for a given surgical procedure is a complex medical judgment made by the physician based on the beneficiary’s individual clinical needs and preferences and on the general coverage rules requiring any procedure be reasonable and necessary.”
• CMS reminds you that removal from the IPO List does not require the procedure to be performed only on an outpatient basis and that the “2-Midnight” rule continues to be in effect and was established to provide guidance on when an inpatient admission would be appropriate for payment under Medicare Part A (inpatient hospital services).

Impact on Medicare Payment Models

Commenters

• Numerous commenters believe this could potentially impact two current Medicare payment models (Bundled Payment Care Initiative (BPCI) and Comprehensive Care for Joint Replacement (CJR) Model). They expressed concern that younger and healthier patients would be more likely to undergo outpatient TKA’s and that TKA patients in the Inpatient setting would be higher risk and/or likely to need additional post-acute care support. This shift could increase average episode payment affecting a hospital’s ability to fall below an episode established target price.

CMS Responds

• Initially, CMS does not expect a significant volume of TKA cases to shift to the hospital outpatient setting as a result of removing this procedure from the IPO List. They do “intend to monitor the overall volume and complexity of TKA cases performed in the hospital outpatient department to determine whether any future refinements of these models are warranted.”

After consideration of public comments CMS finalized their proposal to remove the TKA procedure described by CPT code 27447 from the IPO List beginning in CY 2018 and to assign the procedure to C-APC 5115 with status indicator “J1”.

Moratorium on Recovery Audit Contractor (RAC) TKA reviews

CMS also finalized the proposal to prohibit RAC “reviews for patient status for TKA procedures performed in the inpatient setting for a period of 2 years to allow time and experience for these procedures under this setting.”

Public Requests for “Removal of” or “Additions to” Procedures on IPO List

Request for “Removal”

CMS notes there were requests to remove several additional procedures from the IPO List. The following table includes CPT codes that were requested to be removed.  

‍Request for “Additions to”

One commenter requested adding CPT 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, and combination of intracoronary stent, arthrectomy and angioplasty, including aspiration thrombectomy when performed, single vessel) to the IPO List because this is an emergent procedure to treat acute myocardial infarction patients.

Codes Finalized for “Removal from” or “Addition to” the IPO List in CY 2018

The following table details the finalized changes to the CY 2018 IPO list.

‍Should Partial Hip Arthroplasty (PHA) & Total Hip Arthroplasty (THA) be removed from IPO List?

As a reminder, in the CY 2018 OPPS Proposed Rule, CMS requested public comments to several questions related to whether or not PHA (CPT code 27125 (Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)), and THA, CPT code 27130 (arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft) procedures should be removed from the IPO List.

CMS further sought comment on whether these procedures meet criteria to be added to the ASC Covered Procedures List and how removing these from the IPO List would affect the BPCI and CJR models.

In the Final Rule CMS thanks commenters for their detailed responses and will consider them in future policymaking. So for now, hip procedures remain on the IPO List. Section IX. Procedures That Will Be Paid Only as Inpatient Procedures can be found on pages 657 through 685 of the unpublished Final Rule.

Resources:

Link to unpublished CY 2018 OPPS/ASC Final Rule:  

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1678-FC.html

Note: The Final Rule is schedule to be published in the Federal Register on 11/13/2017

Link to CY 2018 OPPS/ASC Final Rule Fact Sheet: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-01.html