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    CMS Wants to Reinstate Musculoskeletal Procedures – But Not Primary TKA or THA – to the IPO List

    In a move intended to ensure the safety of Medicare beneficiaries, the Centers for Medicare and Medicaid Services (CMS) is proposing to halt the phased elimination of the Inpatient-Only (IPO) list, a policy that was adopted for calendar year (CY) 2021. Nearly 300 musculoskeletal procedures are affected.

    Primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) remain off the IPO list, as they were removed before 2021, but conversion to THA, revision THA, hip fracture, knee arthroplasty with a hinge prosthesis, revision TKA, shoulder arthroplasty, and revision total shoulder arthroplasty are among the procedures that would be reinstated to the IPO list in CY 2022 under the CMS proposal.

    This policy change is outlined in the Calendar Year 2022 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule from CMS, which was posted online on July 19 with a 60-day comment period. The final rule with comment period is scheduled for early November, with the rule planned to be in effect on January 1, 2022. 

    The change to the IPO list, proposed and then finalized during the previous administration, was done without applying long-standing criteria for safe removal of a procedure from the list, CMS said. That review has now been completed, and it was determined that none of the musculoskeletal procedures meet the criteria for removal, with insufficient supporting evidence that the services could be safely performed on Medicare beneficiaries in the outpatient setting. Further, CMS said that based on the review, “we do not believe it would be appropriate for Medicare to pay for these services when performed in an outpatient setting.”

    The new CMS proposal, therefore, is to add the musculoskeletal procedures back to the IPO list for CY 2022 and then do one of the following moving forward:

    • Maintain the IPO list
    • Maintain the longer-term objective of eliminating the IPO list
    • Maintain the IPO list but continue to streamline the list of services

    With that in mind, CMS has asked surgeons and other stakeholders to respond to these specific questions during the 60-day comment period:

    • If CMS were to eliminate the IPO list in the future, what is a reasonable timeline for doing so? What method do stakeholders suggest CMS use to approach removing codes from the list?
    • If CME were to maintain the IPO list but continue to streamline it, what method do stakeholders suggest CMS use to systematically scale the list back to allow for the removal of codes, or groups of codes, that can safely and effectively be performed on a typical Medicare beneficiary in the hospital outpatient setting? The goal is to ensure that inpatient-only designations are consistent with current standards of practice.
    • What effect do commenters believe the elimination or scaling back of the IPO list would have on safety and quality of care for Medicare beneficiaries?
    • What effect do commenters believe elimination or scaling back of the IPO list would have on provider behavior, incentives, or innovation?
    • What information or support would be helpful for providers and physicians in their considerations of site-of-service selections?
    • Should CMS’s clinical evaluation of the safety of a service in the outpatient setting consider the safety and quality of care for the typical Medicare beneficiary or a smaller subset of Medicare beneficiaries for whom outpatient provision of a service may have fewer risk factors?
    • Are there services that were removed from the IPO list in CY 2021 that stakeholders believe meet the longstanding criteria for removal from the IPO list and should continue to be payable in the outpatient setting in CY 2022? If so, what evidence supports the conclusion that the service meets the longstanding criteria for removal from the IPO list and is safe to perform on the Medicare population in the outpatient setting?

    Daniel K. Guy, MD, president of the American Association of Orthopaedic Surgeons (AAOS), said that “AAOS is encouraged to hear that CMS has heeded the patient safety concerns of the physician community regarding the abrupt elimination of the Inpatient-Only List. We continue to support the removal of procedures [that] have been proven to be done safely in the outpatient setting; however, there is much work left to be done to clarify what these changes mean in order to avoid widespread confusion and unintended consequences for patient care.

    “Now, as the agency reassesses how it will evaluate future procedures for removal and the longer-term plan for the IPO, [CMS] should place more emphasis on physicians leading those decisions and prioritize the value of patient choice. CMS must also be careful to avoid creating new regulatory barriers to determining the appropriate setting of care as an overcorrection to the policy reversal – especially now, after the country has benefited from such flexibilities and individualized medicine during the COVID-19 pandemic.

    “Transparency around these changes and input from the medical community are critical to the successful implementation of the rule.”

    A fact sheet on the CY 2022 OPPS/ASC Payment System proposed rule (CMS-1753-P) can be found here.

    The rule in its entirety can be found here. The section on the IPO list begins on page 347: IX. Proposed Services That Will Be Paid Only as Inpatient Services.