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CMS Proposes Total Knee and Total Hip Outpatient Changes

The Centers for Medicare and Medicaid Services (CMS) has more to say about knee and hips in this year’s proposed rule on outpatient payments.

In 2018, CMS successfully removed total knee arthroplasty (TKA, CPT code 27447) from the inpatient only list (IPO) in its Outpatient Prospective Payment System/Ambulatory Surgical Center Payment System final rule. CMS has proposed to keep it that way for 2020.

The ASC Covered Procedures List (CPL) is, as one expects, a list of covered surgical procedures that are eligible for payment under Medicare when performed in an ASC. These represent procedures that, in part, would typically not be expected to pose significant risks to beneficiary safety, and for which the recipient would not typically be expected to require additional levels of monitoring and care.

For 2018, CMS sought comments on whether total knee replacement should be added to the ASC CPL. Some commenters felt that many ASCs are equipped to perform total knees, and surgeons are increasingly performing them safely and effectively on non-Medicare and appropriate Medicare patients. Conversely, others voiced opinions that the majority of ASCs were not well-equipped, and most Medicare patients are not the right candidates for “overnight” joint replacement in such a setting. Total knees didn’t make the list for that year.

For 2020, CMS is proposing to add total knee replacement and knee mosiacplasty to the ASC CPL. Comments will be gathered to learn of any limitations on these procedures in an ASC. (Further, CMS is seeking comments on ways that the role the ASC CPL can improve the physicians’ ability to determine the setting of care as appropriate for the patient.)

Moving to hips, CMS is proposing to remove total hip arthroplasty (THA, CPT code 27130) from the inpatient only list, to be eligible for payment by Medicare in both hospital inpatient and outpatient settings. CMS stopped short of proposing to remove partial hip arthroplasty (CPT code 27125) from the IPO list, because they hold that it does not meet the criteria for removal.

Of course, various camps of for and against stakeholders voiced opinions on total hip replacement in the past, based on factors like patient screening, experience levels of medical teams and appropriately equipped outpatient facilities.

Industry has been readying their outpatient strategies under the belief that it’s only a matter of time before CMS greenlights total knees and hips in ASC settings. Next year may be the year.

CMS will solicit comments on the proposed changes before finalizing their payment coverage.