News: Inpatient or outpatient? For knee replacements, confusion reigns

Confusion and a lack of guidance about Medicare knee replacement rules has caused many hospitals to treat all Medicare beneficiaries undergoing total knee arthroplasty (TKA) as outpatients, according to a survey by the American Association of Hip and Knee Surgeons.

That’s the unintended consequence of removing TKA from the Medicare inpatient-only list of procedures in the 2018 Medicare Outpatient Prospective Payment System final rule, the AAHKS says.

According to the survey, which was published in the Journal of Arthroplasty, 59.5% of surveyed AAHKS members said that their hospitals have instructed them that all Medicare TKAs should be scheduled as outpatient procedures, HealthLeaders Media reported.

CMS noted in its rule that just because a procedure has been taken off the inpatient only list “does not require the procedure to be performed only on an outpatient basis” and that physicians should use their expertise to determine which patients should have the procedure performed as an inpatient or as an outpatient.

However, the 2-midnight rule and a lack of clear admission documentation expectations have caused some hospitals to take a reactionary approach to the change, according to HealthLeaders Media.

The Journal of Arthroplasty also says that “some local Medicare Advantage contractors began to expect outpatient status for all or most TKA cases,” despite the fact that CMS built a provision into the 2018 final rule prohibiting Recovery Auditors from reviewing patient status for TKA for two years.

In addition to possible patient safety issues with treating all Medicare beneficiaries as outpatients for their TKAs, the survey also revealed the rule’s documentation, billing, and administrative consequences:

• 49.8% of respondents said that if the patient was admitted, but did not stay a second midnight, they would be treated as outpatients
• 43.4% reported that the hospital will seek a change in status to inpatient for patients who stay fewer than two midnights
• 40.5% have been asked to use proscribed documentation to justify that change
• 30.4% of surgeons say that their patients have incurred added personal cost related to their TKA being billed to CMS as an outpatient procedure
• 76.1% say that the issue has become an administrative burden

The authors say that it’s AAHKS’s position that “CMS needs to provide more specific expectations concerning the needed language justifying admission or exempt TKA from the 2-midnight rule to mitigate the unintended confusion demonstrated by hospitals and some payers that has resulted from the removal of TKA from the inpatient only list.”

Editor’s note: This article originally appeared in HealthLeaders Media. To read the full survey results, click here. To read about the 2018 inpatient only list removals, including TKA, click here. To read about the 2-midnight rule, click here.