Annually, using established criteria, the CMS reviews the “inpatient only” (IPO) list to determine which, if any, procedures are to be removed. In a previous newsletter, we mentioned how Total Knee Arthroplasty may be removed from the Medicare Inpatient Only list. The winners for CY 2017 are five spine procedures along with two laryngoplasty procedures. Total knee arthroplasty (TKA) procedures did not make the final cut.

Total Knee Arthroplasty

Illustration of a Total Knee Arthroplasty procedure

The CY 2017 OPPS/ASC final rule discussed comments it received regarding the removal of (TKA) from the IPO list. Despite the overwhelming support for its removal, the CMS did not propose making an immediate change, but “will consider all of these comments in future policy making.”

The Medicare Claims Processing Manual refers to IPO services as generally, but not always, surgical services that require inpatient care because of the nature of the procedure, the physical condition of the patient, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. Regardless of the expected length of the hospital stay, IPO list procedures must be performed on an inpatient basis in order to qualify for Medicare payment.

Procedural Criteria for Removal from IPO List

The CMS includes the following in their deliberations to remove a procedure from the IPO list:

  • The procedure is being performed in numerous hospitals on an outpatient basis.
  • The procedure can be appropriately and safely performed in an ASC, and is on the list of approved ASC procedures or has been proposed by CMS for addition to the ASC list.
  • Most outpatient departments are equipped to provide the services to the Medicare population.
  • The simplest procedure described by the code may be performed in most outpatient departments.
  • The procedure is related to codes already removed by CMS from the IPO list

The Public Weighs-in on Total Knee Arthroplasty Removal from IPO List

CMS solicited comment from the public regarding the removal of TKA from the IPO list. Public responses almost universally supported removing TKA from the IPO list. Those that chimed in voicing this position included ASCs and surgeons along with hospital and therapeutic professional associations.

While supporting the removal, most responders “noted that an appropriate patient selection protocol should be used to determine the patients who are best suited for outpatient joint replacement.”

The overwhelming public comment mirrors that of the CMS’s own Advisory Panel on Hospital Outpatient Payment which unanimously recommended CMS remove TKA from its inpatient-only list.

The few dissenters cited concerns around Medicare patients’ needing rehabilitation that is best performed in an inpatient setting; concern that most outpatient departments are not equipped to provide that level of postoperative care; and effect on existing CMS payment models.

CMS response to these comments was that they “thank the stakeholder public for the many detailed comments on this topic. We will consider all of these comments in future policy making.”

Thus,“honorable mention” for removal of TKA from the IPO list, but not in 2017. Perhaps next.year.

Safety and Efficacy of Outpatient Arthroplasty – An ASCs Experience

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Sohrab Gollogly, MD – Monterey Peninsula Surgery Center

Sohrab Gollogly, MD – Monterey Peninsula Surgery Center presented his ASC’s experiences in the Safety and Efficacy of Outpatient Arthroplasty at a 2016 conference hosted by the Ambulatory Surgery Center Association. His presentation includes the following successes and conclusions based on outpatient TKA procedures performed at Monterey Peninsula Surgery Center.

  • Conclusion: CMA should consider TKA to be removed from the inpatient-only list.
  • Professional Support: Over 100 peer-reviewed articles have been published.
  • Medicare Patients Benefits: Appropriate Medicare patients will benefit from outpatient TKA by shorter hospital/ASC stays; good pain control; minimal risk of readmission or post-operative ER visits.
  • Society & Taxpayer Benefits: Outpatient TKA procedures at 50% of the cost of inpatient; clinical outcomes and patient satisfaction scores equal to or better than the inpatient environment.

 

ASCs – Opportunity & Preparation

Given the foregoing, it is likely that outpatient TKA will become a reality. The anticipated positive financial impact for outpatient TKA facilities is significant. In 2015, Medicare covered about 450,000 inpatient TKA procedures with costs totaling more than $7 billion for hospitalization alone. And the average Medicare payment for surgery, hospitalization and recovery ranges from $16,000 to $33,000, depending on where the surgery is performed.

amb_surgery

The lack of removal of TKA from the IPO list by the CMS surprises many, especially given the volume and uniformity of both public and professional comment.

While there is no current projection of how many of these procedures could have been performed in an outpatient facility, clearly most any percentage will result in considerable savings … and significant increased capacity for ASCs that are prepared to provide compliant outpatient TKA services.

Technological advancements, procedural refinements, professional experiences with positive patient outcomes coupled with financial savings appears to be the ingredients for approval of the CMS proposal to expand TKA to properly equipped and staffed ASCs. ASCs interested in adding TKA to its surgical procedures should begin planning for the necessary facility, medical equipment and staff to qualify for participation.

 

 


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