When the Centers for Medicare and Medicaid Services (CMS) removed total knee arthroplasty (TKA) from the inpatient-only list, it committed to suspending audits by Medicare Recovery Audit Contractors (RAC) for two years. The suspension was to serve as a grace period for the industry to acclimate to the new policy; however, all other classes of Medicare audits were left in place – such as those by quality improvement organization (QIO) contractors. Under the CMS Two-Midnight rule, QIOs assume the task of reviewing claims with questions over appropriate admission status, and we have seen some QIOs performing audits and making reversals.

Given AAHKS’s documentation of ongoing confusion among facilities of the Two-Midnight rule, and CMS’ reluctance to clearly articulate when and how it will apply its Two-Midnight rule exceptions policy, AAHKS believes it is inappropriate and counter-productive for CMS contractors to be auditing these procedures now.

In order to work with Congress and CMS regarding appropriate versus inappropriate medically-necessary admissions, we need your help. A survey will be forthcoming to help us understand your experiences with different QIO denial and approvals through the selection and documentation process. In the meantime, we are seeking any examples of QIO documentation that you would be willing to share.

Since outpatient TKA for Medicare fee-for-service (FFS) beneficiaries is a new procedure, it is not clear what documentation would be considered by QIOs to support such a determination. AAHKS requested clarification and provided its own suggested outpatient selection protocols that would function as standards for review for QIOs. CMS has declined to adopt these to date or state how it would evaluate exceptions.

CMS said that it would defer to specialty societies to develop TKA outpatient selection criteria. In order to work with Congress and CMS regarding appropriate versus inappropriate medically-necessary admissions, we need your help. A survey will be forthcoming to help us understand your experiences with different QIO denial and approvals through the selection and documentation process. In the meantime, we are seeking any examples of QIO documentation that you would be willing to share, including:

  • Examples of QIO denials in which the patients clearly did not meet the standards for outpatient TKA as articulated in AAHKS’s proposed exception document provided to CMS
  • Examples of denials in which patients clearly did not meet the standards for outpatient TKA as articulated in any other publicly available resources
  • Examples of TKAs under Two-Midnight rule that were audited and approved by the same QIO as above
  • Any anecdotes or examples (with facility names) where patients were surprised by their out-of-pocket obligations associated with an outpatient TKA.

These examples will allow us to review and find any difference in the review standards applied by QIOs. Please do not include any protected health information (PHI). Any reference to your name, location or institution will be blinded. You can email the QIO documentation to AAHKSStaff@aahks.org and complete a TKA patient anecdote here. Your input is important as AAHKS continues to work on this issue.

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