Q: Has TKA been removed from the IPO?
A: Yes,
CMS finalized the removal of the TKA
procedure described by CPT code 27447 from the IPO list beginning CY 2018. The
TKA procedure will be assigned to comprehensive APC C-APC 5115 (Level 5
Musculoskeletal Procedures) with status indicator “J1” (hospital Part B
services paid through a C-APC).
Q: When does this go into effect?
A: January
01, 2018
Q: Does the removal of TKA from the IPO eliminate the ability to
perform TKA as an inpatient procedure?
A: Absolutely
not. In fact, Medicare explicitly stated
that they still expect most TKAs to be performed on an inpatient basis. There
is a small subset of patients that could appropriately receive outpatient TKAs.
It is for this minority of patients that Medicare is removing the requirement
of inpatient surgery.
Q: How will this change affect reimbursement?
A: The IPO
list status of a procedure has no effect on the MPFS (Medicare Physician Fee
Schedule) professional payment for the procedure.
Q: How will the removal of TKA from the IPO impact the BPCI and
CJR models?
A: CMS does not anticipate a substantial impact on the patient-mix for the
BPCI and CJR models because it does not expect a
significant volume of TKA cases to move from the hospital inpatient setting.
Q: Will CMS create guidelines or protocols for patient selection?
A: While CMS believes that some
less medically complex TKA cases could be appropriately and safely performed on
an outpatient basis, they do not expect to create or
endorse specific guidelines or content for the establishment of providers’
patient selection protocols. CMS acknowledges the importance of deferring
to patients and providers to decide the appropriate site of service for a
particular patient.
Q: Will TKA be subject to RAC audits?
A: The RAC will not
begin to audit these cases for site of service until 2020 and it will not be
retroactive. The delay in RAC
for a period of 2 years will allow providers sufficient time to gain experience
with performing these procedures in the outpatient setting.
Q: Will the
“2-midnight” rule continue to be in effect?
A: “The “2-midnight” rule continues to be in
effect and was established to provide guidance on when an inpatient
admission would be appropriate for payment under Medicare Part A (inpatient
hospital services).
Q: How will this affect patient’s ability to go into a skilled
nursing facility for rehab?
A: There
have been no changes to policies regarding skilled nursing facility (SNF) coverage. A
prior inpatient hospital stay of at least 3 consecutive days is required
by law under Medicare FFS as a prerequisite for SNF. However, Medicare
Advantage plans may elect, to provide SNF coverage without imposing the SNF
3-day qualifying stay requirement and CMS has issued conditional waivers of the
3-day qualifying stay requirement as necessary to carry out the Medicare Shared
Savings Program and to test certain Innovation Center payment models, including
the Next Generation ACO Model.
Q: Are there other
procedures that are being considered for removal from the IPO?
A: CMS plans
to remove additional procedures from the IPO in future years. Moreover, there is interest in procedures
appropriate for addition to the Ambulatory Surgery Center (ASC)-approved procedure
list. CMS stated it will consider the
following arthroplasty procedures to be both removed from the IPO and added to
the ASC in future rules.
- Total hip
arthroplasty (CPT Code 27130)
- Hip
hemiarthroplasty (CPT Code 27125)
- Total
shoulder arthroplasty (CPT Code 23472)
- Shoulder
hemiarthroplasty (CPT Code 23470)
- Total
ankle arthroplasty (CPT Code 27702)
- Revision
total ankle (CPT Code 27703)
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