AAOS Slams CMS’ Rule to EXCLUDE Hip Replacement From Inpatient Only List

AAOS’ anger and astonishment at the new Center for Medicaid and Medicare Service (CMS) rule removing the Inpatient Only (IPO) designation for total hip arthroplasty was apparent in the surgeon society’s November 9 press release.

The very public rebuke came directly from the desk of AAOS President Kristy L. Weber, M.D., FAAOS.

She said, in part, “AAOS is extremely disappointed with CMS’ decision to remove hip replacements from the inpatient-only list beginning 2020.”

Worse, CMS’ decision came one year after a similar ruling removing knee replacements from the IPO list which resulted in unintended consequences which, in Weber’s words, “continue to plague Medicare providers and threaten patient safety.”

Furthermore, said Weber, “It is both troublesome and disheartening to know that the repeated concerns of the surgical community were not heeded in making this critical change to the delivery of care.”

Why Pick a Fight With 34,000 Orthopedic Surgeons?

Founded in 1933, The American Academy of Orthopaedic Surgeons (AAOS) is the world’s largest medical association of musculoskeletal specialists. The academy provides musculoskeletal education to orthopedic care providers all over the world.

The care providers of the musculoskeletal community literally treat more patients, generate more revenue for hospitals and suppliers and affect more healthcare sectors—oncology, cellular and molecular biology, sports, aging and chronic inflammation—than any other sector of medicine.

Why challenge this group—especially when the issue at stake is the safety of roughly one-fourth of the U.S. population?

CMS’s final rule states:

This rule finalizes changes to the Inpatient Only (IPO) list including removal of total hip arthroplasty, six spinal surgical procedures and certain anesthesia services from the list, making these procedures eligible to be paid by Medicare in the hospital outpatient setting in addition to the hospital inpatient setting. The decision on the appropriate site of service is a complex medical judgment made by the physician based on the clinical characteristics of the patient. The 2-midnight rule offers guidance on when payment is generally appropriate under Medicare Part A or Part B.

Also, in response to public comments, we are establishing a two-year exemption rather than the one year we proposed, from certain medical review activities relating to patient status for procedures removed from the inpatient-only list beginning in CY 2020 and subsequent years.

Under this policy, Beneficiary Family Centered Care-Quality Improvement Organization (BFCC-QIO) reviews of short-stay inpatient claims for procedures that have been removed from the IPO list within the first two years will be for medical necessity of the underlying services and to educate providers and practitioners regarding compliance with the 2-midnight rule, but claims will not be denied based on patient status (that is, site of service) alone.

Furthermore, these procedures will also not be eligible for referral to the Recovery Audit Contractor (RAC) for noncompliance with the 2-midnight rule for a two-year period after their removal from the IPO list. This two-year exemption period will allow providers time to update their billing systems and gain experience with respect to newly removed procedures eligible to be paid under either the Inpatient Prospective Payment System (IPPS) or OPPS, while avoiding potential adverse site of service determinations. [emphasis added]

AAOS Raises Safety Alarms in Letter to CMS

In a September 27, 2019 letter to CMS Director Seema Verma, AAOS President Weber told Director Verma that AAOS “strongly opposes” removal of total hip arthroplasty (CPT code 27130) from Medicare’s inpatient-only list.

Weber cited safety issues in her letter starting with five key criteria which ensure that the procedures being performed in the outpatient setting are appropriate for that setting. The five criteria were:

1. Assure that the outpatient department is equipped to provide services to the Medicare population of older patients with a wide range of co-morbidities.
2. Allow the simplest procedure described by the code to be performed in most outpatient departments.
3. Allow any procedure to be performed in the outpatient setting that is properly described by codes that we have already removed from the IPO list.
4. Ensure that the procedure is already being performed in numerous hospitals on an outpatient basis.
5. Ensure that the procedure can be appropriately and safely performed in an ASC setting and is on the list of approved ASC procedures or has been proposed by AAOS for addition to the ASC list.

Unfortunately, as Weber wrote in her letter, CMS was only considering the 2nd and 3rd of these criteria—namely to allow the simplest hip arthroplasty procedure described the code and any other procedure which has already been removed from the IPO list.

The remaining three safety criteria were ignored.

AAOS’ Specific Recommendations to CMS

In that September 27 letter, AAOS reminded CMS that total joint procedures in an ambulatory surgery center (ASC) are appropriate ONLY for carefully selected patients who are in otherwise excellent health with no or limited medical co-morbidities and sufficient caregiver support.

Those assurances, however, were lacking from CMS’ final rule.

So, President Weber reminded Director Verma of the distinctions between inpatient and outpatient settings and how CMS policies (or lack thereof) would affect total joint arthroplasty patient safety.

Specifically:

• Total joint arthroplasty is a more invasive procedure with a greater risk of complications such as bleeding, deep vein thrombosis and pulmonary embolism than, for example, less invasive hip or knee procedures.
• Best practices for lowering the incidence of total joint arthroplasty adverse events is often available only in the inpatient setting and through use of ancillary services in the postoperative and preoperative periods.
• Only surgeons and physicians have the expertise to determine patient selection for total joint arthroplasty in the ASC setting.
• Not all ASCs or outpatient departments are the same. Surgical site selection must be weighted in light of local conditions and availability of aftercare, home care, transportation and facility capability to treat certain orthopaedic conditions.
• Commercial payers attempts to interpret CMS’ rules to restrict patient access to appropriate care settings on the basis of cost alone.
• Forcing care to an outpatient or ASC setting when not appropriate.

What’s Next?

Since AAOS’ recommendations failed to sway CMS, President Weber is now recommending that “CMS adequately prepare for the effect of these concerning changes. Physicians must be trusted and empowered to designate the best practice setting for their patients, and not be crippled by the burden of proof.”

“Additionally, the statutory requirements of MACRA [Medicare Access and CHIP Reauthorization Act] section 523(a) must be upheld to ensure integrity of the relative value scale and appropriate access to surgical care. We hope that the agency recognizes these impending challenges and is thoughtful about the enforcement of these new policies.”

For more information:

Here are the relevant weblinks to both the CMS ruling and AAOS’ recommendations.

• OPPS/ASC final rule
• AAOS on OPPS/ASC proposed rule
• MPFS final rule
• AAOS on MPFS proposed rule

Finally, to lend your voice in support of AAOS’ efforts go to the following website—AAOS advocacy.