2018 OPPS final rule: CMS removes total knee arthroplasty from inpatient-only list

While the 2018 OPPS final rule may be controversial for its payment cuts to drugs purchased through the 340B drug discount program, it contains several provisions supported by hospitals and other stakeholders.

CMS will be removing CPT code 27447 (arthroplasty, knee, condyle and plateau; medical and lateral compartments with or without patella resurfacing [total knee arthroplasty]) from the inpatient-only list in 2018 after soliciting provider feedback on the procedure over the last two rulemaking cycles. The procedure has been assigned to APC 5115 and status indicator J1 (paid through a comprehensive APC).

While many stakeholders commented that the procedure could be performed successfully on an outpatient basis, others noted that removing it from the inpatient-only list could have an impact on Medicare’s Bundled Payments for Care Improvement (BPCI) and Comprehensive Care for Joint Replacement (CJR) program. With the procedure removed from the inpatient-only list, some providers are concerned that younger, healthier patients will have the surgery as an outpatient and skew BPCI and CJR statistics.

However, CMS writes in the final rule that it does not expect a “significant volume” of such cases to shift from the inpatient to outpatient setting despite being removed from the list, but will monitor overall volume and complexity of cases to determine future refinements of the models.

Additionally, CMS will prohibit Recovery Auditors from reviewing patient status for total knee arthroplasty procedures performed in the inpatient setting for two years while providers gain experience with performing the procedure in the outpatient setting. The agency will still permit reviews for other reasons, such as medical necessity.

CMS also removed the following procedures from the inpatient-only list for 2018:

• 43282, laparoscopy, surgical, repair of paraesophageal hernia with implantation of mesh
• 43772, laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only
• 43773, laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only
• 43774, laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components
• 55866, laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance, when performed

Each has been assigned status indicator J1.

CMS added one code to the inpatient-only list, 92941 (percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, single vessel), which has been assigned status indicator C (inpatient-only procedure procedure not paid under OPPS).

The 2018 OPPS final rule is available here and CMS has also released a fact sheet summarizing the major provisions.