Federal Regulatory Wins

The AAOS Office of Government Relations’ regulatory efforts ensure that orthopaedic concerns are addressed even after the conclusion of the legislative process and throughout agency rulemaking and implementation stages. To this end, the regulatory staff works closely with Department of Health and Human Services agencies such as the Food and Drug Administration (FDA), Centers for Medicare & Medicaid Services (CMS), the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Disease Control and Prevention (CDC). In addition, expertise in coding, reimbursement, and payment policy is shared across the Academy and with our members. The Office of Government Relations also houses the AAOS’ practice management information and educational efforts. Both of these are key services to our fellowship and members.

Scoliosis Screening

On January 9, 2018, the United States Patient Safety Task Force (USPSTF) released updated guidance on screening for adolescent idiopathic scoliosis. The guidance was upgraded from “D”, discouraging screening, to “I”, indicating the data is inconclusive on the effectiveness of screening. POSNA and SRS led a letter in June 2017 signed by 13 other BOS societies as well as AAOS and the American Academy of Pediatrics urging the USPSTF to upgrade their recommendation. Read the USPSTF’s announcement here.

Medicare Access and CHIP Reauthorization Act (MACRA) and the Quality Payment Program

The Quality Payment Program—which replaces the flawed Sustainable Growth Rate (SGR) formula as required by MACRA—includes two tracks: the Merit-based Incentive Payment System (MIPS) track and the Advanced Alternative Payment Models (APMs) track. AAOS has been working closely with CMS to address a number of concerns related to the Quality Payment Program, including the need for additional flexibility and simplification, as well as protection for small, solo, and rural practices.

Most recently, AAOS submitted comments to CMS on its proposed rule that would make changes in the second year of the Quality Payment Program, including participation requirements for 2018. The 2018 Quality Payment Program proposed and final rules took significant steps to respond to AAOS’ concerns for needed flexibility and simplification, as well as protection for small, solo, and rural practices.

Specifically, AAOS applauded a number of provisions in the MIPS track to decrease the burdens on solo and small practices (defined as 15 or fewer eligible clinicians). These provisions included:

  • higher low-volume threshold (now $90,000 or 200 Medicare beneficiaries)
  • significant hardship exemption from Advancing Care Information
  • a 5-point bonus to the MIPS final score
  • 3-point scoring for measures that do not meet data completeness.

AAOS also commented on new proposals for virtual groups and the need for provision of clinician/practice data. Finally, AAOS commented that we look forward to working on “redesigning Medicare value-based payment models such that they are voluntary, physician-led, have accurate price setting, and provide access to data for all participants.” Read the entire AAOS comment letter online here.

“The Quality Payment Program remains overly complex and there are continued issues regarding access to data and Advanced APM qualification for specialists, but we are encouraged by proposals that improve the program for providers and ensure quality care for Medicare beneficiaries.” – Wilford K. Gibson, MD, Chair, AAOS Council on Advocacy

Visit the AAOS MACRA resource page for all materials and updates: www.aaos.org/macra

For any questions, concerns, or comments, email macra@aaos.org

Bundled Payment Models

In August of 2017, CMS announced changes that address significant concerns raised by AAOS related to mandatory bundled payment programs. First, the changes reduce the number of mandatory geographic areas participating in the CMS’s Comprehensive Care for Joint Replacement (CJR) model from 67 to 34. In addition, the changes would allow CJR participants in the 33 other areas to participate on a voluntary basis. CMS also proposed to make participation in the CJR model voluntary for ALL low volume and rural hospitals in all of the CJR geographic areas. Finally, CMS cancelled the Surgical Hip and Femur Fracture Treatment (SHFFT) payment model and others that were scheduled to begin on January 1, 2018.

“AAOS applauds Secretary Price, Administrator Seema Verma, and others at CMS for clearly hearing concerns of orthopaedic surgeons related to these mandatory payment models.” – AAOS President William J. Maloney, MD

On January 9, 2018, CMS announced a new voluntary bundled payment model that will qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program. This new model, called “Bundled Payments for Care Improvement Advanced” (BPCI Advanced), requires participants to bear financial risk, have payments under the model tied to quality performance, and use Certified Electronic Health Record Technology. The pricing methodology of this new model no longer relies on the National Trend Factor (NTF), as AAOS has consistently argued that the NTF is detrimental to the sustainability of BPCI models. AAOS has some additional concerns – including the model’s interaction with CJR, the semi-annual reconciliations, and benchmark price consideration – but is working to ensure interested orthopaedic surgeons have the tools and resources to participate. This includes a well-attended webinar, which aired on February 21, 2018, and formal communications with CMS.

For the webinar and to read more about these issues, visit: www.aaos.org/advocacy/medicarepaymentcms/ 

Regulatory Relief

Throughout the year, the Department of Health and Human Services has issued several requests for information, proposed rules, and other documents that indicate their commitment to reducing many of the day-to-day burdens that orthopaedic surgeons face. For example, CMS recently launched the “Patients Over Paperwork” Initiative, a cross-cutting, collaborative process that evaluates and streamlines regulations with a goal to reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience. According to CMS, this effort emphasizes a commitment to removing regulatory obstacles that get in the way of providers spending time with patients. The recently-released Medicare Physician Fee Schedule final rule includes the following as part of this initiative: (1) reducing reporting requirements and (2) removing downward payment adjustments based on performance for practices that meet minimum quality reporting requirements.

“We recognize and appreciate that CMS has recently released a number of RFIs and has encouraged stakeholder input on new policies to better achieve transparency, flexibility, program simplification, and innovation.” – AAOS President William J. Maloney, MD

Additionally, AAOS responded in July 2017 to a CMS RFI on reducing regulatory burdens. Issues raised by AAOS included MIPS reporting requirements, Medicare claims data, the need for Stark law reform, and issues related to the restrictions on physician-owned hospitals. Read the entire comment letter online here

As a result, AAOS was pleased with a CMS announcement in January 2018 about the creation of an interagency task force to review the federal Stark law.

Total Knee and the Inpatient Only List (IPO) 

On November 1, 2017, CMS finalized the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System rule, which includes updates to the 2018 rates and quality provisions, and other policy changes. Importantly, the rule finalizes changes to the Medicare IPO list for CY 2018. AAOS applauded CMS for removing total knee arthroplasty (TKA) from the IPO list and for acknowledging this decision should be “made by the physician based on the beneficiary’s individual clinical needs and preferences.” AAOS further acknowledged CMS for noting that the surgeons, clinical staff, and medical specialty societies who perform outpatient TKA and possess specialized clinical knowledge and experience” are most suited to create guidelines to identify appropriate candidates.

Read the AAOS press release on the announcement online here.

AAOS continues to work with stakeholders as this change is implemented. To that end, AAOS recently released a FAQ document with answers to questions related to this decision. Read the FAQ online here. AAOS also wrote a letter to CMS discussing some concerns with the implementation of this policy change.

For the letter and to read more about these issues, visit: www.aaos.org/advocacy/medicarepaymentcms/ 


After AAOS communicated serious concerns to CMS, the agency withdrew a proposed rule that would have added substantially more onerous qualifications needed for practitioners to furnish and fabricate prosthetics and custom-fabricated orthotics than current law requires. AAOS applauded the decision to withdraw it and avoid adding burdensome and unwarranted requirements related to prosthetics and orthotics. Read the AAOS press release on this issue online here.

Accrediting Organizations

In early 2017, CMS proposed to revise the application and re-application process for Accrediting Organizations (AOs), specifically related to transparency by requiring AOs to post provider/supplier survey reports and plans of corrections from CMS-approved accreditation programs on their public-facing websites. AOs currently do not make their survey reports and acceptable points of care from their CMS-approved accreditation programs publicly available. AAOS opposed the publication of quality improvement surveys and plans of correction by AOs in current form. After consideration of the comments received, CMS decided that it would be best if the proposal was not finalized and instead, the proposal was withdrawn.

Accounting for Social Risk Factors and Risk Stratification

In comment letters to CMS, AAOS has argued that risk stratification and adjustment are equally significant components of valid quality assessment. Providers should not be financially penalized when caring for patients with greater needs. CMS has recognized the importance of risk stratification and adjustment and has said they will consider the analyses and recommendations from a report that analyzes the effects of certain social risk factors in Medicare beneficiaries on quality measures and measures of resource use used in one or more of nine Medicare value-based purchasing programs, as well as reports that include considerations for strategies to account for social risk factors in these programs. Furthermore, CMS awaits the recommendations of the National Quality Forum (NQF) trial on risk adjustment for quality measures.


After consideration of comments from AAOS and others that CMS received, CMS is reassigning TAR procedure codes from MS DRG 470 to MS DRG 469, even if there is no MCC (Major complication or comorbidity) reported for FY 2018. As the Medicare claims data demonstrated, there is substantial cost difference between TAA and other lower extremity joint replacements. Read more online here.

AAOS continues to work on issues related to coding and reimbursement which include review and comment of new and revised CPT codes, proposed National Correct Coding Edits (NCCI) procedure-to-procedure edits, proposed CMS Medical Unlikely Edits, and issues related to ICD-10CM and ICD-10PCS. In addition, AAOS develops educational material and updates to the Academy’s coding products such as the Global Service Data for Orthopaedic Surgery book and the Code-X program as well as coding courses held throughout the year.


In 2017, AAOS announced plans to create a national family of clinical data registries for a broad range of orthopaedic conditions and procedures. As part of this effort, the American Joint Replacement Registry (AJRR) is integrating into the AAOS. The AJRR, a national hip and knee joint replacement registry with 970 participating U.S. hospitals and 40 ambulatory surgery centers, has captured and analyzed data on more than one million procedures since its creation in 2010.

On June 23, 2017, AAOS and AJRR participated in a meeting with 16 high-level CMS and CMMI staff to successfully resolve the problem the registry has encountered accessing Medicare claims data. AJRR was encouraged to utilize the ResDAC program, and is the first QCDR to do so. After three years of working on this issue, AAOS is anticipating receipt of the first delivery of Medicare claims data to AJRR at any time. AAOS also continues to advocate for full implementation of Section 105(b) of MACRA.