AAOS to CMS: Decision for outpatient TKA should remain patient-surgeon choice

In response to a request from CMS for comments on its Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems proposed rule, the American Association of Orthopaedic Surgeons, or AAOS, noted some concerns about the proposal in comments submitted to CMS in a letter dated Aug. 30.

According to an AAOS press release, the concerns conveyed in the AAOS letter to CMS were related to computed/digital radiograph changes, social risk factors and risk stratification, physician-owned hospitals (POHs) and health care system flexibilities.

Ahead of the close of the comment period on Sept. 11, orthopedic surgeons, including Orthopedics Today Chief Medical Editor Anthony A. Romeo, MD, lobbied in Washington, D.C., in favor of moving total joint arthroplasty to the outpatient procedures list.

“It is more critical now than ever to be a part of the conversations happening on Capitol Hill,” Romeo told Healio.com/Orthopedics. “With legislative reform efforts continuing, critical issues like outpatient joint arthroplasty, the opioid crisis that affects all of us and frequent regulatory changes shaping how we practice medicine, we must ensure the unified orthopedic voice breaks through the noise. Working with the American Academy of Orthopaedic Surgeons, I saw firsthand that we have the tools to make this happen. And, it is especially true in DC, that there is power in numbers. So, whether you are a first-time advocate or a seasoned veteran, your participation on these issues can make a huge difference,” Romeo said.

Physicians should determine site of surgery

In its response to CMS about the part of the rule about removing total knee arthroplasty (TKA) from the Medicare inpatient-only (IPO) list, which also includes procedures only paid for under the Hospital Inpatient Prospective Payment System, AAOS said in the release that it supports removing TKA, as well as total hip arthroplasty (THA) from the IPO. However, the removal should be contingent on the orthopedic surgeon being the final arbiter of the appropriate site for where the procedure is performed, according to the release.

“We ask that this be explicitly stated in the final rule,” William J. Maloney, MD, AAOS president, wrote in the AAOS letter to CMS.

In the letter, Maloney highlighted the need for a comprehensive preoperative plan for certain patients undergoing knee arthroplasty and certain types of prostheses used.

He wrote, “The determination of how to best provide adequate and timely care to a Medicare beneficiary should fall under the purview of the patient-surgeon relationship, as these are the individuals who shoulder the risk of these procedures.”

Maloney wrote that support of the proposal by the AAOS was also contingent on there being clear criteria for surgical site and patient selection. In addition, he noted the AAOS favored having payments remain site neutral.

Continued cooperation between CMS, AAOS

“There has been significant movement toward performing TKA in the outpatient setting, and AAOS supports removal of TKA from the Medicare in-patient only list with several contingencies,” Maloney said in the release. “The patient’s health and well-being must always be the first priority. Therefore, the determination of how to best provide adequate and timely care to Medicare patients should fall under the purview of the patient-surgeon relationship. Additionally, there should be clear criteria for surgical site selection and it should be noted that an outpatient TKA procedure would be appropriate only for carefully selected patients. To that point, AAOS is currently developing measures to assist selection of the ideal candidate for these procedures. We look forward to continuing to work with CMS on this and other outpatient and ambulatory surgery center issues.”

Concerning CMS possibly removing THA and partial hip arthroplasty from the IPO list and adding these to the ASC Covered Surgical Procedures List, the AAOS noted in its letter that clarification of partial hip arthroplasty is needed. Among other comments in the letter, AAOS urged CMS to consider removing some added CPT codes from the IPO list and including them on the ASC list, such as CPT 27702 for total ankle arthroplasty and CPT 23472 for total shoulder arthroplasty. – by Susan M. Rapp

 

 

Reference:

AAOS letter to CMS, Aug. 30, 2017