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Published 9/1/2008
Jacque Roche; Lindsay Law

CMS issues final IPPS rule

Three conditions added to HAC payment policy

Under the final inpatient prospective payment system (IPPS) rule updating Medicare payments to hospitals for fiscal year 2009, the Centers for Medicare and Medicaid Services (CMS) added three new conditions to the list of hospital-acquired conditions (HAC) for which Medicare will not pay at the enhanced complication/comorbidity payment level.

Because two of the three conditions relate directly to orthopaedic procedures, many AAOS fellows have expressed considerable concern about their impact. This article attempts to address those concerns.

Two issues should be clarified immediately. First, Medicare will continue to pay for the primary procedure or service. Second, this hospital inpatient policy does not affect physician payments; it only affects payments to the acute inpatient hospital setting.

The following three conditions were added in the final rule:

  • surgical site infection (SSI) following certain elective pro¬≠cedures (including orthopaedic procedures)
  • deep vein thrombosis/pulmonary embolism (DVT/PE) in total knee replacement (TKR) and total hip replacement (THR)
  • manifestations of poor glycemic control

Differences from the original proposal
Although CMS originally proposed SSI in TKR as a potential HAC, the final rule does not include TKR among the elective orthopaedic procedures under the SSI HAC. Additionally, the DVT/PE HAC is limited to TKR and THR patients only.

The total impact of the DVT/PE HAC is that for primary (not revision) hip and knee patients who do not have other significant comorbidities and who sustain a PE (not a DVT) during their initial hospitalization, hospitals will not be eligible to receive an incremental reimbursement based on the existence of PE alone. This is much different from statements that CMS will not pay for DVT/PE after elective orthopaedic procedures because development of a DVT does not actually have payment implications for TKR and THR. Therefore, this policy affects an extremely small number of patients.

Finally, CMS reduced the original 43 proposed measures for the hospital quality data reporting program to 13 finalized measures. Because the hospital inpatient setting is on a fiscal year cycle, the policy goes into effect on Oct. 1, 2008.

AAOS efforts
The American Association of Orthopaedic Surgeons (AAOS) met with CMS several times and submitted comments on SSI in TKR and DVT/PE as HACs. On June 13, 2008, AAOS submitted a comment to CMS on the HAC payment policy.

AAOS proposed changes to the musculoskeletal Medicare severity diagnosis-related groups (MS-DRGs) but CMS did not accept any of them.

The AAOS shares the CMS goal of promoting high-quality, safe, and effective care, but is concerned that including complications that are not always reasonably preventable to the HAC list may have unintended consequences that could negatively affect patient access and quality of care. The AAOS will respond with a strong comment and meeting to discuss the potential threats on patient access to orthopaedic care.

Jacque Roche is a federal policy analyst and Lindsay Law is communications manager in the AAOS office of government relations.