Posted: 11/03/2017

he Centers for Medicare and Medicaid Services (CSM) has taken total knee arthroplasty (TKA or total hip replacement) off its Inpatient Only List (IOL) effective January 1, 2018.

For those who don’t know, the Inpatient Only List is a list CMS publishes of operations and procedures that must be performed while the patient is an inpatient at a hospital. Those procedures not on the list should be performed in an outpatient setting (outpatient hospital or free standing surgical center) unless admission can be justified under Medicare’s admission regulations.

Orthopedic surgeons have frequently kept their TKA patients for 2 nights after surgery as a routine practice and this wasn’t a problem when all TKAs were done as inpatients. But patients having outpatient surgery are expected to leave before the second midnight. If they stay longer, they should be admitted when there is an acute clinical reason (such as a complication of surgery) for keeping them a second night. This wouldn’t apply if the second night was for convenience; they would remain outpatients.

There has been a lot of chatter on the list-serves about how hospitals and physicians should react to this change. Some of this consternation seems to be a kind of shock triggered by such a seismic change, but we must remember that above all we are required to abide by Medicare regulations as best we can interpret and follow them.

The solution is actually rather straight forward: Under this new rule, TKA should be treated like any other outpatient surgery from a status and billing perspective. In other words, the procedure should be performed as an outpatient unless the physician can justify and document an expectation of a 2-midnight stay or a second night in the hospital is actually needed.

What about patients with multiple comorbidities who are at higher risk of complications? Sorry. Having comorbidities doesn’t qualify for admission unless the comorbidities are causing a recovery that is more complicated than usual and that a specific issue related to that comorbidity prevents safe release from the hospital. In some cases, however the surgeon can admit if there’s a documented treatment plan that encompasses 2 midnights of medically necessary post op hospital care. That’s exactly the way it is for all outpatient surgeries.

In the case of TKR, for those surgeons who don’t believe their patients are ready for discharge before the second midnight, I think it would justify admission if the surgeon documented that the patient "hasn’t sufficiently recovered from surgery to be managed at home because of…" pain, nausea, inability to ambulate, need for nursing monitoring of X, etc. These may not be “inpatient diagnoses” per se but they would explain why a surgeon believed that a post op patient “isn’t ready to go home" and that they have admitted the patient because they “require a second night of post operative care in the hospital.” I don’t know if that would fly with auditors, but hopefully it’s the truth - and the that docs won’t abuse such a tool to continue with their old ways.

For those post ops who are ready to jump out of bed, congratulations, they should be out before the second midnight and would remain outpatients.
The principle, as always, is "Do the right thing for the patient."

Here's a little ditty that covers all outpatient surgery and that is so simple even an orthopedic surgeon can master it (OK, kidding):

If they're ready to go home,
Let them fly.
If they need another night,
Just write why.