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    CMS Wants to Remove Musculoskeletal Services from the Inpatient-Only List – and Then Eliminate the List

    Last year, the Centers for Medicare and Medicaid Services (CMS) announced that the agency was removing total hip arthroplasty (THA) from the Inpatient-Only List for Medicare patients in 2020, just as they did with total knee arthroplasty in 2018.

    CMS has now signaled that they want to be even more aggressive with the Inpatient-Only List in calendar year 2021. In the newly released Hospital Outpatient Prospective Payment System, CMS proposes to remove all 266 musculoskeletal-related services – including revision hip and knee arthroplasty, hip fracture fixation, and spine procedures – from the list next year as the first phase of eliminating the Inpatient-Only List altogether. They envision a 3-year transitional period, with the list completely phased out by calendar year 2024.

    RELATED: CMS Is Removing THA from the Inpatient-Only List

    Procedures removed from the IPO list will eventually become subject to the 2-midnight rule, but for now, “we propose to continue the 2-year exemption from certain medical review activities relating to patient status for procedures removed from the IPO list beginning in [calendar year] 2020 and subsequent years,” CMS said.

    For calendar year 2021, CMS also proposes to add 11 procedures to the covered procedures list for ambulatory surgery centers, including THA (CPT 27130), and to adjust the criteria for procedures covered in the ambulatory setting. In addition, CMS proposes to remove certain restrictions on the expansion and development of physician-owned hospitals.

    Joseph A. Bosco III, MD, President of the American Association of Orthopaedic Surgeons (AAOS), said that AAOS supports CMS’s goal of giving orthopaedic surgeons and patients more choice regarding the care setting, but the organization is concerned about the potential for unintended consequences associated with eliminating the Inpatient-Only List.

    “In pushing forward such a drastic change, CMS may exacerbate many of the same unresolved issues that our surgeons continue to face as a result of hip and knee arthroplasty being recently removed from the Inpatient Only List,” Dr. Bosco said.

    “Payers, including Medicare Advantage and commercial carriers, often misinterpret the policy change to mean that these procedures must be performed exclusively in the outpatient setting. This confusion adds even more delay and paperwork to existing prior authorization requirements and, most importantly, jeopardizes patients’ safe, timely access to care.”

    Determining the site of care for an individual patient should be based on patient-safety considerations and peer-reviewed evidence, Dr. Bosco added, with physicians taking the lead in the decision-making process with their patients.

    “We strongly encourage CMS to carefully reassess this aspect of the proposal in light of these concerns, and we look forward to offering our formal comments on behalf of the musculoskeletal community,” he said.

    The Federal Register notice can be found here. The rationale for eliminating the Inpatient-Only List, starting with musculoskeletal services, begins on page 375, with the list of services beginning on page 386.