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:
- Assure that the outpatient department is equipped to provide services to the Medicare population of older patients with a wide range of co-morbidities.
- Allow the simplest procedure described by the code to be performed in most outpatient departments.
- 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.
- Ensure that the procedure is already being performed in numerous hospitals on an outpatient basis.
- 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.
