Posted: 3/01/2018

Having listened to the recording of the February 26, 2018 Open Door Forum (ODF) (I was unable to listen live) several issues remain unresolved.

Centers for Medicare and Medicaid Services (CMS) representatives reiterated their earlier position on the requirements for admission of a Medicare patient having total knee arthroplasty (TKA) following removal of the procedure from the inpatient only list, but left unanswered questions that have caused great consternation in the minds of physicians and hospitals.

To be specific, if TKA can be performed in either the inpatient or outpatient setting, what are the criteria for inpatient admission? In the 2018 Inpatient Prospective Payment System (IPPS) final rule, CMS stated that it expects most of these procedures to continue to be done in an inpatient setting, that it expects professional societies to develop guidelines for admission, and that appropriateness for admission will be judged on a case-by-case basis.

But there are problems:

1. Despite their expectation that professional societies will develop guidelines for admission, CMS will not accept any of those guidelines (nor InterQual nor MCG) as a basis for admission and Part A payment.
2. While stating that the need for post acute skilled care should be taken into account in the decision to admit, the need for such care will not be accepted as a reason to admit and a medically necessary 3-night inpatient stay is still required for a patient to qualify for post acute skilled nursing facility admission.
3. The two-midnight rule remains the basis for admission but CMS cannot (will not) give any guidance on the specific criteria that justify admission nor how the Quality Improvement Organizations (QIOs) have been instructed to review one-midnight inpatient stays.
4. CMS stated that “nothing has changed” in the review of admission for TKA; it is no different than any other procedure that is removed from the inpatient only list and admission should be a “complex medical judgment” made by the admitting physician. That judgment, however, is subject to review and the admission subject to denial if the Medicare reviewer, who many not be a physician, determines, by unstated criteria, that admission was not warranted under the 2-midnight rule.
5. As stated in the 2016 IPPS final rule, based on the physician's "complex medical judgment" inpatient admission and Part A payment may be warranted for some patients whose stay is not expected to require 2 midnights of hospital care. This flies in the face of language in the 2014 IPPS final rule, which established the 2-midnight rule and stated that except for procedures on the inpatient only list there is no difference between inpatient and outpatient care. Indeed, in that final rule CMS stated that patients receiving outpatient observation may even receive care in an ICU.
6. Patients having outpatient surgery in a hospital are treated in the same facility and have the same clinical services available in both inpatient and outpatient settings. In fact, they are not different settings at all; they are just different types of billing for the same service.
7. If there is no difference in care, how can a physician possibly justify (and a reviewer judge) the need for inpatient care when the 2-midnight expectation and/or benchmark have not been documented or met?
8. When CMS said that it expected most TKAs to continue to be performed as inpatients, it misled hospitals. Prior to taking the procedure off the inpatient only list, all Medicare TKAs were performed as inpatients. Now the physician must do the procedure as an outpatient unless they can document a 2-midnight expected stay or meet some other as yet undefined standard that would justify admission without that expectation. Many hospitals have found that a majority of their TKAs are now being performed as outpatients. 

The Open Door Forum gave hospitals a chance to ask lots of questions but the answers were less than satisfying; they left ambiguity and confusion.

The main problem seems to me to be that CMS said that it did not expect many TKAs to be performed as outpatients, yet, by imposing the requirements of the 2-midnight rule, that is exactly what is happening.

The message from the ODF was pretty clear: Either perform the procedure as an outpatient and bill Part B or document either the need for a 2-midnight stay (and the need for post acute SNF care is not reason enough) or as-yet undefined conditions that require inpatient care (whatever that is). Relying on any set of guidelines, whether from nationally published criteria, a professional society or a local medical staff invites denial.

Bottom line: TKA ain't nuthin' special to CMS so if you think you have found a way to continue performing these formerly inpatient only procedures as inpatient and making the outpatient care the exception, based on the answers we heard from CMS at this ODF, I say, "fergetaboutit".