CMS Is Removing THA from the Inpatient-Only List

    The Centers for Medicare and Medicaid Services (CMS) has published its final rule on the Medicare Hospital Outpatient Prospective Payment System (CMS-1717-FC) and the Ambulatory Surgical Center Payment System for calendar year 2020, and as orthopaedic surgeons have been expecting, total hip arthroplasty was removed from the Inpatient-Only List.

    In addition, total knee arthroplasty has been added to the Ambulatory Surgery Center Covered Procedures List.

    The comment period for this final rule ends on Monday, December 2, and the rule is scheduled to take effect on January 1, 2020.

    CMS says that the changes in the rule, “build on existing efforts to increase patient choice by making Medicare payment available for more services in different sites of services and adopting policy changes under the Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System.”

    In a September 27 letter to Seema Verma, MPH, Administrator for CMS, the American Academy of Orthopaedic Surgeons (AAOS) had strongly objected to CMS removing THA from the Inpatient-Only List, citing the confusion that followed removal from TKA from the list in 2018.

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    “Notwithstanding our support of patient choice, the proposal to move total hip arthroplasty (THA) to an outpatient hospital setting is rash,” the letter said. “THA is an invasive procedure for which a limited set of patients are strong candidates for the hospital outpatient department (HOPD).

    “Considering the confusion precipitated by the removal of total knee arthroplasty (TKA) from the inpatient only (IPO) list in 2018, it is troubling to imagine the ways this change may be misconstrued by payers.”

    CMS says removing THA from the Inpatient-Only List makes the procedure,eligible to be paid by Medicare in the hospital outpatient setting in addition to the hospital inpatient setting.” It also acknowledges that, “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.”

    A statement from AAOS, attributed to President Kristy L. Weber, MD, FAAOS, reiterates the organization’s concern over removing THA from the Inpatient-Only List, “especially as the removal of knee replacements in 2018 and the unintended consequences of that policy change continue to plague Medicare providers and threaten patient safety. 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.

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    “Furthermore, CMS is setting a dangerous precedent for the future of musculoskeletal procedures and their perceived value – despite our aging population. In failing to apply updated evaluation and management values to global codes for 2021, the agency has chosen to blatantly disregard recommendations from the medical community and disrupt the relativity mandated by Congress for the Medicare fee schedule. For orthopaedics, this will mean an unfair differential in future reimbursements for specialty care.

    “Our ask now is that CMS adequately prepare for the effect of these concerning changes. Physicians must be trusted and empowered to designate the best practice setting for their patients, and not be crippled by the burden of proof.

    “Additionally, the statutory requirements of MACRA section 523(a) must be upheld to ensure integrity of the relative value scale and appropriate access to surgical care. We hope that the agency recognizes these impending challenges and is thoughtful about the enforcement of these new policies.”

    The final rule published in the Federal Register can be read by clicking here.