Posted: 2/10/2018
In an article in the February ACPA Newsletter, Drs. Hirsch and Banker debate (to over simplify a bit) whether total knee replacement (TKR) should be performed as outpatient and admitted only if they require a second midnight of hospital care (Dr. Banker) or whether the Centers for Medicare and Medicaid Services (CMS) has granted more leeway in admitting these patients compared to other outpatient surgery based on comorbidities and the expectation of the need for post-operative skilled nursing care (Dr. Hirsch).
Dr. Hirsch makes some excellent points. So does Dr. Banker. And on November 3, 2017 I posted an ACPA Blog ("Outpatient Total Knee Arthroplasty? You Betcha") favoring Dr. Banker's approach.
Bottom line: I think we're all right.
How can differing interpretations all be right?
It's the yin and yang of Medicare compliance - where nothing is as it seems. CMS says one thing ("Treat TKR differently from all other outpatient surgery") yet the reviewers may say otherwise ("Don't forget the 2-midnight rule").
I says, "Ya pays yer money and ya takes yer chances." In other words, hospitals must decide whether they want to allow admission of TKRs based on comorbidities and expectation of the need for SNF or do most of them as outpatient and admit the ones that require a second night in the hospital. The latter strategy relies less on the whim of the reviewer so it's less likely to trigger a denial but the former, while risking more denials, better ensures qualification for SNF (for those who need it), takes CMS at its word (which might not be such a good idea), and might just enhance the hospital's bottom line (though that shouldn't drive the decision).
A final thought: If you bill inpatient and get a denial from the QIO, you can still rebill Part B and get paid the outpatient rate so nothing is lost except the cost of rebilling unless (ouch!) the QIO decides that your inpatient billing is an abuse and refers you to the RAC - not a pleasant outcome al all!
Be sure to read the Newsletter articles and don't miss the comment at the very bottom in which Cheyenne Santiago, RN, MSN, Clinical Lead for Medical Review for WPS Government Health Administrators reports that her QIO has "informally" said that they'll be following the 2-midnight rule for TKR.