AAHKS is seeking additional examples of patient care problems related to the removal of total knee arthroplasty (TKA) from the Centers for Medicare & Medicaid Services (CMS) Inpatient Only list (IPO). As a compelling example, a member recently reported on the negative impact this has had on his practice and care for his patients. If you have had an experience related to this issue that has hindered patient care, we would like to hear from you. These first-hand anecdotes will aid us our work with CMS and Congress as we seek a solution to this issue.
Member Report
The removal of TKR from the in-patient only list has certainly created its share of problems. As stated by AAHKS, “Unfortunately, the unintended consequence of this change has been an unprecedented amount of confusion on the part of a variety of stakeholders regarding how to interpret this new rule. Hospitals, surgeons, and payers are interpreting the rule from different perspectives and as such are each coming to very different conclusions,” the society said in a statement. Our hospital’s initial interpretation of the ruling was that all TKRs were now outpatient procedures, which obviously was not true.
The system where I practice has hired a consultant to review compliance. The consultant is of the opinion that very few, if any, Medicare TKRs qualify for in-patient status. In spite of the statements from AAOS, AAHKS, and, most importantly, CMS itself that the majority of TKRs will continue to be in-patient procedures, he has convinced our administrators to the contrary. Their review of traditional Medicare TKRs performed in the system since January 1 has determined that only 0.25% qualify for inpatient status. The system is now in the process of adjusting and resubmitting the bills for these patients. The end result to the patient is that the bill is now covered under Medicare Part B, not Part A. Unless the patient has medication coverage, they will now be billed for all the medications they took while in the hospital since medications under Part B are “self-administered” and not covered. This has resulted in patients receiving bills for up to several thousands of dollars, depending on how many meds were administered. Additionally, the hospitalists who followed the patients as “in-patients” are now being told their services will not actually be covered. Our system administrators have described the issue as “non-negotiable.”
While the consultant understands that CMS will not retrospectively change the admission status for any TKR performed before 2020 through an audit, the consultant states that this is Medicare fraud as viewed by the OIG and the responsible party is the physician that wrote the admission order.
This issue becomes even more complex with the start of BPCI Advanced.
As we know, CMS did not intend that each inpatient TKA, the current care standard, required such documentation of medical need. Rather, they expected, as stated clearly in the rule, that the vast majority of TKAs would remain inpatient.
