Which Medicare Patients Undergoing TKA Should Be Inpatients versus Outpatients?

    Dr. James Browne answers ICJR’s questions about the removal of total knee arthroplasty from the Medicare inpatient-only list and shares a scoring tool he and his colleagues at the University of Virginia developed to evaluate TKA patients.

    ICJR: Since removing total knee arthroplasty (TKA) from the inpatient-only (IPO) list, has the Centers for Medicare and Medicaid Services (CMS) provided any guidance to hospitals and surgeons on its expectations for which TKA patients should be inpatients and which should be outpatients?

    James A. Browne, MD: We have been frustrated at our institution by the lack of guidance from CMS. They have made it clear that the ultimate decision regarding inpatient or outpatient status rests with the physicians. However, that does not mean that a physician’s decision will be acceptable to CMS and hold up to an audit, nor is it clear what documentation is required to support this decision.

    There is also uncertainly surrounding the 2-midnight rule and its application to TKA. Even patients meeting the 2-midnight threshold may not meet medical necessity requirements for inpatient hospital care in the documentation.

    ICJR: What do surgeons need to document to justify that an inpatient admission is necessary for a TKA patient covered by Medicare? Does the literature provide any criteria for inpatient versus outpatient TKA in this population?

    Dr. Browne: This is really the crux of the matter. We don’t know yet what documentation will satisfy CMS. There is an emerging body of literature to help guide this decision, but whether CMS will agree that a given criteria is acceptable to justify an inpatient admission remains unknown.

    The consensus in the arthroplasty community is that surgeons should work with their hospital administration and utilization management staff to create protocols for designating status that take into account:

    • Comorbidities
    • Functional status
    • Risks of surgery
    • Risks of anesthesia
    • Anticipated need for intensive medical management in the postoperative period
    • Discharge needs

    ICJR: You and your colleagues at the University of Virginia have been working on a scoring tool to set criteria for inpatient admission of TKA patients covered by Medicare. Would you share the tool and what you’ve learned in the process of developing it?

    Dr. Browne: A retrospective examination of recent TKA patients at our institution was undertaken to develop our criteria. Our goal was to develop a tool that had a reasonable predictive value, that was easy to administer, and that was based on our past experience with our patient population. The resulting tool (Figure 1) takes into account not only the potential medical and orthopaedic needs of our patients, but also their social needs and potential barriers to discharge to home. The physician can always overrule the tool using clinical judgement when necessary.

    Although we are still in the process of examining and analyzing the results of using this tool, our initial impression is that it has been pretty accurate and safe thus far.

    3 or more, place IP order
    <3, place outpatient order
    >6, additional physician review needed
    Inpatient status is also warranted if severity of any comorbidity will require close inpatient monitoring for 2 or more nights in the judgment of the surgeon.

    Figure 1. UVA TKA CMS IPO Screening Tool

    Author Information

    James A. Browne, MD, is an Associate Professor in the Department of Orthopaedic Surgery at the University of Virginial School of Medicine, Charlottesville, Virginia. He is also head of the Division of Adult Reconstruction and Vice Chair of Clinical Operations.

    Disclosures: The author has no disclosures relevant to this article.