A new study appearing in the January 2020 edition of The Journal of Arthroplasty, “The Clinical and Financial Consequences of the Centers for Medicare and Medicaid Services’ Two-Midnight Rule in Total Joint Arthroplasty,” used the National Inpatient Sample to examine the conflicts involved in the aforementioned rule.
Adam J. Schwartz, M.D., M.B.A., associate professor of orthopedic surgery at the Mayo Clinic College of Medicine in Phoenix, Arizona and study co-author described the issues raised by CMS’ [Centers for Medicare and Medicaid Serivces] two-midnight rule for TKA inpatient-only list to OTW, “We were seeing more confusion among patients and providers since removal of TKA [total knee arthroplasty] from the inpatient-only list.”
“Arthroplasty surgeons have become much better at TKA over the past few decades, and rapid recovery protocols have become more prevalent. Thus, hospital stays have declined such that the majority of patients now leave the hospital in less than three midnights, and a very large proportion leave even before two midnights. These latter patients were previously labelled ‘short-stay inpatient hospitalizations’ [SSIH] because they did not cross at least two midnights.”
“Arthroplasty surgeons and hospitals had little awareness of this, however, because TKA was on the inpatient-only list before January 1, 2018, which made this procedure an exception to the two-midnight rule. Prior to the policy change in 2018, whether a patient stayed 1 night, 2 nights, or 5 nights didn’t matter—they were allowed to be billed as inpatient only.”
“This problem is compounded by the fact that such a large proportion of Medicare patients stay less than two-midnights following TJA [total joint arthroplasty]. Prior research has shown that most hospitals will bill SSIHs as outpatient cases (through Medicare Part B), most likely due to fear of audit.”
“A rational arthroplasty surgeon might define an ‘outpatient’ case as follows: a patient undergoes surgery and leaves the hospital on same day. Much of the confusion surrounding CMS’ new TJA policy stems from the fact that the CMS definition of outpatient care has little to do with a patient actually leaving the hospital on the same day. In fact, patients billed for outpatient services can commonly be in the hospital overnight or even longer.”
“Surgeons are still largely insulated from these issues because the professional payment to the surgeon is billed separately to Part B, independently of the facility inpatient or outpatient status billing. On the other hand, the surgeon is a key driver of the hospital’s inpatient vs. outpatient billing decision, the treating physician typically decides if a two-midnight stay is medically necessary. As a result, discharge planners and hospital administrative staff rely heavily on surgeon documentation to help determine if it is more appropriate to bill a particular case as inpatient or outpatient.”
“Surgeons should pay attention to co-morbidities and medical conditions that warrant keeping the patient in the hospital two midnights and document these issues thoroughly.”
“Perhaps the most interesting finding of our work is that on average, the negative financial effects to hospitals are more pronounced when a hospital bills a SSIH as outpatient, rather than keeping the patient an extra night (assuming the extra night is ‘medically necessary’ and the treating physician documents appropriately).”
“In an effort to encourage shorter hospital stays, our analysis demonstrates that the removal of TKA (and now THA [total hip arthroplasty]) from the inpatient-only list has actually created a financial incentive for hospitals to keep patients longer.”
“The shift to true outpatient surgery (same day discharge) requires appropriate patient selection, development and utilization of rapid recovery protocols, and appropriate postoperative care and patient monitoring. The CMS recognizes that the shift to true outpatient surgery requires more than just a simple policy change, and that the standard of care continues to be inpatient hospitalization.”
“Given this recognition we believe that the CMS should consider placing TKA back on the inpatient-only list and provide a completely separate Comprehensive Ambulatory Payment Classification code for outpatient TJA. This code would then require the burden of proof to be placed on documenting that outpatient care is appropriate, rather than the other way around.”
“The CMS should also provide more exceptions to the two-midnight rule for surgical cases such as TJA where a large portion of patients stay less than two midnights but may be inappropriate for discharge on the same day as surgery.”
