The American Association of Hip and Knee Surgeons have stated that hip and knee replacements can be safely performed in the outpatient setting in some specific circumstances. However, the wording implies the procedure is most appropriate in an ideal patient when performed in a facility and by a surgical team specifically equipped for this type of procedure. The clear implication is that an outpatient procedure should not be a viewed as an appropriate or mandatory setting for arthroplasty procedures.

I. Orthopaedic Society FORMAL positions regarding Outpatient Arthroplasty Surgery

The most relevant statement was published on 10/10/18 by the American Association of Hip and Knee Surgeons (AAHKS).  This position was officially endorsed by major relevant Orthopaedic Societies including:

• The American Academy of Orthopaedic Surgeons (AAOS)
• The Hip Society
• The Knee Society

The societies note that their priority is:

“preserving patient safety and outline specific recommendations for surgeons and institutions considering discharge of hip and knee replacement patients on a same-day outpatient basis.”

The essential elements identified they identified that require optimization are:

• Patient selection (on medical grounds)
• Patient education and expectation management (e.g. preoperative “joint school”) • Social support and environmental factors (family or professional outpatient support)
• Clinical and surgical team expertise
• Institution facility or surgery center factors (history of successful team work and an environment conducive to optimizing surgical outcomes)
• Evidence based protocols and pathways for pain management, blood conservation, wound management, mobilization, and VTE prophylaxis.
• In addition:
• Special attention should be paid to proper patient selection when considering outpatient same-day discharge for total hip and knee arthroplasty.
• Medical comorbidities should be minimal and patients should generally be relatively healthy, active, and at low risk for medical or surgical complications.

Society conclusion:

“It is our position that some total hip and knee replacements can be appropriately performed in the outpatient setting with safe discharge the day of surgery if the above-mentioned factors, elements, and sufficient practitioner and surgeon experience are maintained…If a patient is not appropriate for discharge home on the day of surgery, facilities and staff such as, in an overnight care suite or hospital, must be available to ensure patient safety.”

SUMMARY

The societies clearly state that TKA and THA can be safely performed in the outpatient setting in some specific circumstances.  However, the wording implies that outpatient arthroplasty is most appropriate in an ideal patient when performed in a facility and by a surgical team specifically equipped for this type of procedure.  The clear implication is that an outpatient procedure should not be a viewed as an appropriate or mandatory setting for arthroplasty procedures.

Outpatient Arthroplasty Surgery

II. Orthopaedic Society FORMAL positions regarding Outpatient Arthroplasty Surgery and Medicare’s Inpatient-Only List (IPO)

TKAs were removed from the IPO effective 1/2018; THAs were removed effective 1/2020.

In letter dated 9/27/19, AAHKS formally submitted comments to CMS on their Proposed Rule to remove THA from the IPO list.  Similarly, to what they had said in 2017 regarding TKAs, AAHKS noted that:

“Regarding removal of THA from the IPO, we prefer that more time is given for health providers and plans to familiarize themselves with proper patient selection for TKA in the outpatient setting before proceeding with removing THA from the IPO.”

In fact, in this 2019 letter they reiterated what they had said a prior letter from 9/11/17 that:

“Most outpatient departments are not currently equipped to provide THA to Medicare beneficiaries. Execution of outpatient THA requires excellent patient selection and education, tailored anesthetic techniques, well done surgery, good medical care, and exceptional post-operative care coordination. Very few hospitals have executed all of these elements to date. We are not aware of any data to confirm the safety and efficacy of outpatient THA in Medicare beneficiaries.”

AAHKS did acknowledge that:

”Nevertheless, if CMS proceeds with removing THA from the IPO, AAHKS acknowledges that in a setting with excellent patient selection and education, tailored anesthetic techniques, well done surgery, good medical care, and exceptional post-operative care coordination, it may be clinically appropriate for some Medicare beneficiaries to have the option of a THA procedure as a hospital outpatient.”

AAHKS raised specific concerns about hospitals misinterpreting removal of THA from IPO list:

”Based on the experience of our members in dealing with the removal of TKA from the IPO, we have come to learn of the essential role CMS must play in educating stakeholders. It is not a risk but a certainty that some facilities will attempt to make outpatient the default admission status for all THA procedures. We can suspect whether this is done for administratively simplicity, to minimize risk of violating the 2-midnight rule, or some other reason. We do know that in a recent AAHKS member survey, a majority of respondents reported that their hospitals were making outpatient status the default admission status for TKA procedures.”

"The TKA experience tells us that not all hospitals review essential Medicare regulatory preamble language. CMS statements included in the Proposed Rule preamble need to be made directly available to hospitals to ensure hospitals do not improperly pressure THA to be performed on outpatient status. Therefore, we strongly encourage CMS to issue THA-specific MLN guidance, like that issued specific to TKA, to increase the likelihood of hospital awareness of CMS preamble statements on patient selection. It is a fact that CMS is in a better position to educate hospitals nationwide. Otherwise, individual surgeons are left in a position to advocate and educate their hospital billing and compliance departments on Medicare guidance on patient selection.”

AAHKS raised specific concerns about insurers misinterpreting removal of THA from IPO list:

”We also encourage CMS to monitor Medicare Advantage (“MA”) plans for concerning behavior following any removal of THA from the IPO. As we have shared previously with CMS, our members have concerning anecdotal experience of some MA plans citing the removal of TKA from the IPO list as a basis to initially deny coverage for all TKA inpatient admissions. Absent appropriate oversight, some MA plans will continue to use any pretext based on a cursory reading of CMS policy to drive as many THA procedures as possible to the outpatient setting. Further, if any plan denies its enrollees the option of inpatient THA when medically appropriate, the plan will not be adhering to its obligation to make all Medicare FFS benefits available to its enrollees. In our member survey in 2018, 43% of 721 respondents reported that local MA plans had changed coverage policies to declare all/majority of TKAs to be scheduled as outpatient procedures.”

An AAOS NOW (published 10/119) article noted that:

“the AAOS supports the American Association of Hip and Knee Surgeons’ position on the issue. The Academy agrees that until all of the issues regarding TKA removal from the IPO list are addressed, it would be irresponsible to do the same with THA. AAOS further requests that CMS refrain from removing any procedures from the IPO list until the issues that surfaced with the removal of TKA are resolved.”

On 12/1/19, after the Final rule was published removing THA from the IPO list, AAOS President Kristy L. Weber, MD, FAAOS, issued the following statement in response:

“AAOS is extremely disappointed with CMS’ decision to remove hip replacements from the IPO list beginning [in] 2020, especially as the removal of knee replacements in 2018 and the unintended consequences of that policy change continue to plague Medicare providers and threaten patient safety. It is both troublesome and disheartening to know that the repeated concerns of the surgical community were not heeded in making this critical change to the delivery of care.”

On 1/24/2019, Medicare reissued a Medicare Learning Network (MLN) Special Edition Article regarding Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule.  They stated that:

What does Removing TKA from the IPO list mean?

1. This allows TKA procedures to be paid by Medicare FFS when performed in either the hospital inpatient or hospital outpatient setting, assuming all other criteria are met.
2. This allows TKA short-stay inpatient claims (if chosen in a sample of claims) to be reviewed by the BFCC-QIOs for compliance with the 2-Midnight Benchmark or Case-by Case exception (note that the two-year prohibition of RAC review for patient status continues to apply regardless of whether the case is performed on an inpatient or outpatient basis.)

 What does Removing TKA from the IPO list NOT mean? 

1. It does not mean that all TKAs must be performed on a hospital outpatient/observation basis nor does it mean that there is a presumption about where TKAs are performed.
2. It does not mean that TKA Short Stay inpatient claims are targeted for review by CMS.

SUMMARY

The major orthopaedic societies expressed significant reservations on removing both TKAs and THAs from Medicare’s IPO list.  Their reservations were based on many concerns including patient safety issues, as well as concerns regarding misinterpretation of the removal from the IPO list by hospitals and insurers. In fact, they expressly documented their concerns about this misinterpretation by hospitals and insurers in their 2019 comment letter. Medicare attempted to address some of these concerns (at least for TKA) in their MLN Article where CMS clearly reiterated the societies’ position that “removal from the IPO does not mean that all TKAs must be performed on a hospital outpatient/observation basis nor does it mean that there is a presumption about where TKAs are performed.”  The overall wording of the letters, and positions statements from both CMS and the societies is again consistent with the premise that outpatient arthroplasty is most appropriate in an ideal patient when performed in a facility and by a surgical team specifically equipped for this type of procedure.  The clear implication is that outpatient arthroplasty should not be a viewed as an appropriate or mandatory setting for arthroplasty procedures.

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