New codes recognize need for additional resources

In the final inpatient prospective payment system rule for the 2010 fiscal year, the Centers for Medicare & Medicaid Services (CMS) accepted the payment recommendations proposed by the American Association of Orthopaedic Surgeons (AAOS) for the treatment of infected total hip (THA) and total knee arthroplasty (TKA).

The AAOS Health Care Systems Committee formally submitted comments to CMS, supporting the proposal to move revisions for infected THA and TKA into higher paying Medicare Severity-Diagnostic Related Groups (MS-DRGs). The AAOS, in conjunction with the American Association of Hip and Knee Surgeons (AAHKS), has recommended that CMS address the inaccuracy of this reimbursement for the past 3 years.

The CMS policy was based on the following recommendations submitted by the AAOS and AAHKS last year:

• Move ICD-9-CM procedure code 80.05 (Arthrotomy for removal of hip prosthesis) out of MS-DRGs 480-482 (Hip and femur procedures except major joint) and into MS-DRGs 463-465 (Wound débridement and skin graft except hand)
• Move ICD-9-CM procedure code 80.06 (Arthrotomy for removal of knee prosthesis) out of MS-DRGs 495-497 (Local excision of internal fixation device except hip and femur) and into MS-DRGs 463-465 (Wound débridement and skin graft except hand)

Increasing access to treatment
The AAOS and AAHKS explained that the previous level of hospital reimbursement for treating infection following THA or TKA left patients and their physicians in a vulnerable position. Because caring for these patients requires considerable resources, inadequate hospital reimbursement levels made some hospitals reluctant to provide these services.

Deep infection is one of the most devastating complications associated with THA and TKA. Treatment often requires multiple surgeries, prolonged use of intravenous and oral antibiotics, extended rehabilitation (both inpatient and outpatient), and frequent follow-up visits. Both the AAOS and the AAHKS thought it was important to work with CMS to ensure that patients had access to treatment in a timely manner.

This payment reform should help alleviate some of the increased economic burden on the tertiary care referral centers that care for these patients. It should also help reduce treatment delays for patients who are seeking providers willing and able to care for infected joint replacements.

Hospital-acquired conditions
Although the rule did not include new hospital-acquired conditions (HACs), the AAOS and the Pediatric Orthopaedic Society of North America (POSNA) took the opportunity to continue a dialogue with CMS on HAC policies. The AAOS and POSNA expressed concern about the unintended consequences of the HAC policy on the pediatric population, because Medicaid policies frequently mirror Medicare policies.

Noting that CMS presumes that HACs could be reasonably prevented through the use of evidence-based guidelines, the AAOS and POSNA pointed out that evidence-based guidelines cannot eliminate the risk of certain hospital-acquired adverse events, particularly in the pediatric population.

Because pediatric orthopaedic surgery is frequently performed on children with multisystem disease, even when evidence-based guidelines are applied, many children will have postoperative infections. Adding postoperative infections to the HAC list, noted the AAOS and POSNA, might discourage hospitals from treating complicated pediatric patients and thereby limit care for this particularly at-risk population.

The AAOS and POSNA believe that risk adjustment is an indispensible component of an equitable HAC policy. The AAOS, through the Health Care Systems Committee, has submitted comments and met with CMS staff on several occasions on this issue and will continue to advocate for quality and accessibility of musculoskeletal care to patients.

Other issues
The AAOS also took the opportunity to support venous thromboembolism (VTE) quality measures stating: “By identifying patients who develop a VTE who have NOT received appropriate prophylaxis, the measure accounts for compliance with evidence-based guidelines while providing actionable information for quality improvement.”

The comment letter also addressed the proposed changes that would allow new hospital residency training programs to receive a temporary adjustment to their FTE resident caps and recent changes to requirements under the Emergency Medical Treatment and Active Labor Act in the event of a nationally declared disaster or public health emergency.

For more information on advocacy issues, visit the AAOS office of government relations Web site, www.aaos.org/dc

Jacque Roche Buschmann is a federal policy analyst in the AAOS office of government relations. She can be reached at roche@aaos.org

Kevin J. Bozic, MD, MBA, chairs the AAOS Health Care Systems Committee. He can be reached at bozick@orthosurg.ucsf.edu

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