CMS proposes removing total knee replacements, other joint procedures from inpatient-only list

July 23, 2017
Medicare Web

CMS proposed a handful of changes to the inpatient-only list in the 2018 OPPS proposed rule, including the removal of total knee replacement procedures from the list.

The agency sought comments on removing total knee replacements in last year’s OPPS proposed rule and received mixed feedback. CMS said some commenters claimed refinements in surgical technique have made it safe for certain Medicare beneficiaries to undergo a total knee replacement in the outpatient setting, but the agency noted that other commenters claimed there was insufficient research on outpatient total knee replacements to definitively say the procedure would be safe to perform on an outpatient basis.

In the 2018 OPPS proposed rule, the agency is moving ahead with a proposal to remove total knee replacements under CPT code 27447 (arthroplasty, knee, condyle and plateau; medial and lateral components with or without patella resurfacing [total knee arthroplasty]) from the inpatient-only list. If finalized, the procedure would be added to comprehensive APC (C-APC) 5115 (Level 5 Musculoskeletal Procedures) and assigned status indicator J1 (hospital Part B services paid through a C-APC).

CMS said removing the procedure from the inpatient-only list does not prohibit providers from performing it in an inpatient setting; it simply allows payment for the procedure when performed in either the inpatient or outpatient setting. The agency also said it will prohibit Recovery Audit Contractor (RAC) review for patient status for total knee replacements in the inpatient setting for two years, as CMS explained in the rule:

We would not want hospitals to err on the side of inappropriately performing the procedure on an outpatient basis due to concerns about the possibility of an inpatient total knee replacement claim being denied for patient status. That is, given that this surgical procedure would be newly eligible for payment under either the IPPS or the OPPS, RAC denial of a hospital claim for patient status would be prohibited.

In addition to total knee replacements, CMS also proposes removing laparoscopic prostatectomies as described by CPT code 55866 (laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed) from the inpatient-only list. If finalized, this code would be assigned to C-APC 5362 (Level 2 Laparoscopy & Related Services) with status indicator J1.

CMS is soliciting comment on removing partial and total hip replacements from the inpatient-only list. This proposal would affect procedures described by CPT codes 27125 (hemiarthroplasty, hip, partial [e.g., femoral stem prosthesis, bipolar arthroplasty]) and 27130 (arthroplasty, acetabular and proximal femoral prosthetic replacement [total hip arthroplasty], with or without autograft or allograft]). The agency is also soliciting comment on whether to add total knee replacements to the list of ambulatory surgical center-covered surgical procedures.   

Comments on the proposed rule are due by September 11. To learn more about changes from the proposed rule, listen to the upcoming HCPro webinar, “2018 OPPS Proposed Rule: Breaking Down Financial and Organizational Impacts” on August 15 with expert speakers Jugna Shah, MPH, and Valerie A. Rinkle, MPA