CMS Final Rule

CY2020 OPPS and ASC Payment Systems
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CMS Releases CY2020 OPPS and ASC Payment Systems Final Rule

The Centers for Medicare & Medicaid Services (CMS) published the 2020 Medicare Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center Payment Systems Final Rule on November 12, 2019.  In the Rule CMS removed total hip arthroplasty (THA) from the CMS inpatient only list (IPO) and added total knee arthroplasty (TKA) to the Ambulatory Surgical Centers (ASC) Covered Surgical Procedures List (CPL) in CY 2020.

You can read the AAHKS comment letter here, and a summary of the Final Rule, highlighting relevant issues, here.

AAHKS continues to believe there has not been adequate action to address the issues that arose from the removal of TKA from the IPO to now support the removal of THA. With regard to the proposed addition of TKA to the ASC CPL, it is imperative that standards and procedures are in place as part of this change to ensure patient safety.

Total Hip Arthroplasty and the Inpatient-Only List (IPO)

CMS removed CPT code 27130 (THA) from the IPO list. As such, providers will now be reimbursed by Medicare for THA performed during a hospital outpatient stay. Medicare will continue to reimburse providers for THA as an inpatient procedure if the patient’s admission spans at least two midnights.

  • In 2017 CMS sought comments through the OPPS Proposed Rule on the possible removal of partial hip arthroplasty (PHA) and THA. The AAHKS comment letter on the Proposed Rule stated that we did not believe that THA was appropriate for removal from the IPO because “we are not aware of any data to confirm the safety and efficacy of outpatient THA in Medicare beneficiaries.”
  • In a 2018 letter to CMS Administrator Seema Verma, AAHKS stated: In light of the confusion and misinterpretation within the health care industry over the removal of TKA from the IPO list, we believe CMS should postpose any plans to remove total hip arthroplasty (“THA”) from the IPO list in 2019 or 2020. CMS must review an entire year’s worth of claims data under this TKA policy and wait for input from providers who have experienced at least a full-year of the TKA policy. Any decisions that CMS makes regarding THA removal from the IPO list should be made only after assessing the full impact of the TKA removal once the entire health industry comes to a uniform interpretation of the policy.

CMS believes that CPT 27130 meets two of the criteria used in considering the removal of procedures from the IPO: (1) “the simplest procedure described by the code may be performed in most outpatient departments” and (2) the procedure is related to codes that CMS has already removed from the IPO list. CMS invites public comments on whether THA meets these two criteria.

  • Again in the 2017 AAHKS comment letter AAHKS stated: 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.
  • There is no simple 27130 procedure; all are THA procedures with a moderate risk for complications. For the same reason as stated above, most outpatient departments are not prepared to orchestrate an outpatient THA for a Medicare beneficiary. The procedure described by CPT code 27130 is fundamentally different from other procedures.  CMS has proposed removing CPT code 27447 from the IPO in 2018.  THA and TKA are similar in the extent of risks associated with each in moving the site of surgery to an outpatient setting.
  • As we have seen multiple unresolved issues arise since the removal of TKA from the IPO a year and a half ago, we continue to support THA staying on the IPO.
  • In addition, in our member survey of July 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.

CMS notes comments received by stakeholders since 2018 that THA could be provided on an outpatient basis for some Medicare beneficiaries given thorough preoperative screening by medical teams with significant experience and expertise in hip replacement. These comments noted “significant success involving same day discharge for patients who met the screening criteria and whose experienced medical teams were able to perform the procedure early enough in the day for the patients to achieve postoperative goals, allowing home discharge by the end of the day.”

  • AAHKS response: 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. Given the current state of peer-reviewed literature on this topic, guarantees should not be given to willing patients that same-day discharge will be accomplished in all cases.

Total Knee Arthroplasty and Ambulatory Surgical Centers (ASCs)

CMS added TKA to the ASC Covered Surgical Procedures List (CPL) in CY 2020. CMS notes its ongoing policy to promote site neutrality and its agreement “that that there is a small subset of Medicare beneficiaries who may be suitable candidates to receive TKA procedures in an ASC setting based on their clinical characteristics.” CMS further notes: In 2016, more than 800 TKAs were successfully performed in ASCs on Medicare Advantage patients. Following removal of TKA from the IPO, only 18% of TKAs moved from the inpatient to outpatient settings in 2018. CMS solicits public comment on methods to ensure Medicare beneficiaries receive surgical procedures in the ASC setting only as clinically appropriate.

  • AAHKS does not oppose this proposal, but it is imperative that standard procedures such as admitting arrangements with hospitals be developed before this happens, to ensure patient safety remains of paramount concern.