Survey of Surgeons Confirms Hospital Confusion Over Medicare Rules on TKA Patients

    A survey conducted by the American Association of Hip and Knee Surgeons (AAHKS) shows that nearly 60% of surgeon members report their hospitals are interpreting new Medicare rules differently than the Centers for Medicare & Medicaid Services (CMS) intended, possibly to the detriment of some patients.

    In November 2017, CMS finalized the 2018 Medicare Outpatient Prospective Payment System rule that removed total knee arthroplasty (TKA) from the Medicare inpatient-only (IPO) list of procedures. At the time, CMS indicated that only a very small percentage of Medicare patients would be expected to undergo TKA as an outpatient. Studies have shown that careful patient selection is required for successful outpatient knee replacement surgery.

    Instead, many hospitals, as documented by the AAHKS survey, are treating all Medicare beneficiaries as outpatients unless the surgeon seeks a special exception. “This may be creating unsafe conditions for patients,” according to a statement released by AAHKS in February. There are a variety of factors relating to a patient’s health and living circumstances that make inpatient surgery the only safe option, especially for the Medicare-aged patient.

    Another unintended consequence of the rule change is the application of the so-called “2-midnight rule” created by CMS to address overutilization of hospital services in other areas of medicine. In this scenario, a TKA patient who is well enough to be discharged from the hospital after a single overnight stay (less than 2 midnights) is retroactively classified as an outpatient. This affects the patient’s co-pay responsibilities as well as the ancillary services that are covered by Medicare.

    “As surgeons we always seek to improve efficiency and quality, but the safety of our patients is foremost. We hope this confusion can be remedied soon to avoid patient harm,” said AAHKS President Craig J. Della Valle, MD.

    Although the surgeon’s fee is not affected by the new rule, 76% of surgeons report the situation is imposing an administrative burden in their practice. Most importantly, as one respondent wrote, “It doesn’t help to provide better care of our patients.”


    Yates AJ, Kerr JM, Froimson MI, Della Valle CJ, Huddleston JI. The unintended impact of the removal of total knee arthroplasty from the Center for Medicare and Medicaid Services inpatient-only list. J Arthroplasty. 2018 Sep 21. pii: S0883-5403(18)30824-6. doi: 10.1016/j.arth.2018.09.043. [Epub ahead of print]