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In its Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule for calendar year 2020, the U.S. Centers for Medicare & Medicaid Services (CMS) will remove total hip replacement and six spinal surgical procedures from its inpatient only list, effective January 1, 2020.
Specifically, the procedures to be removed are as follows.
- Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft, CPT code 27130
- Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar, CPT code 22633
- Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar; each additional interspace and segment, CPT code 22634
- Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical, CPT code 63265
- Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic, CPT code 63266
- Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar, CPT code 63267
- Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral, CPT code 63268
Removal of these procedures from the inpatient only list makes them eligible to be paid by Medicare in hospital outpatient and inpatient settings.
In response to public comments, a two-year exemption from certain medical review activities relating to patient status for procedures removed from the inpatient only list beginning in calendar year 2020 and subsequent years will be enacted, as opposed to the originally-proposed one-year exemption. The extended period will allow providers time to update billing systems and gain experience with newly removed procedures that are eligible to be paid under either the Inpatient Prospective Payment System or Outpatient Prospective Payment System, while avoiding potential adverse site of service determinations.
Additionally, for 2020, CMS is adding total knee arthroplasty and knee mosaicplasty to the ASC Covered Procedures List. The list covers surgical procedures that are eligible for payment under Medicare when furnished in an ASC. Covered surgical procedures are those that would not be expected to pose a significant risk to beneficiary safety, and for which the beneficiary would not typically be expected to require active medical monitoring and care at midnight following the procedure.
Industry, analysts and healthcare advisors have noted that outpatient total joint replacement and spine procedures would significantly increase upon CMS coverage. The recent announcements highlight that orthopedic device manufacturers should solidify their outpatient strategies for hospital and ASC settings.
