AAOS September 5, 2017
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AAOS Comments on CMS Outpatient Rule, TKA Proposal

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AAOS Comments on CMS Outpatient Rule, TKA Proposal

On August 30, 2017, the American Association of Orthopaedic Surgeons (AAOS) submitted comments to the Centers for Medicare and Medicaid Services (CMS) on its “Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems” proposed rule. The comments highlight a number of concerns, including those related to computed/digital radiography changes, social risk factors and risk stratification, physician-owned hospitals, and needed health care system flexibilities. On the radiography changes, AAOS commented that the reduction in payments for services utilizing computed radiography technology is unreasonable; “providers who offer in-office services to improve access and convenience to patients should not be penalized for using this time-tested technology.” AAOS also called for further hardship exceptions in reporting requirements, electronic health records improvements, and increased access to Medicare claims data.

Importantly, CMS in this rule also proposed removing total knee arthroplasty from the Medicare inpatient-only list, which includes procedures that are only paid for under the Hospital Inpatient Prospective Payment System. The proposed rule further seeks comment on whether partial and total hip arthroplasty should be removed from the list. AAOS supports removal of total knee arthroplasty (TKA) and total hip arthroplasty (THA) from the in-patient only list contingent on several issues, including that the surgeon be the final arbiter of the appropriate site for the surgical procedure; that there are clear criteria for surgical site and patient selection; and that payments remain site neutral.

“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,” stated AAOS President William J. Maloney, MD. “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.”

In addition to removal of TKA and THA from the inpatient-only list (IPO), AAOS asked for clarification of “Partial Hip Arthroplasty (PHA)” plans and requested that CMS consider removing several additional procedures from the IPO, as well as add them to the ambulatory surgical center (ASC) list. AAOS stated it believes these procedures satisfy most, if not all, of the criteria for consideration of removal:

  • CPT 27702 Total Ankle Arthroplasty (TAA) or Total Ankle Replacement (TAR)
  • CPT 27703 Revision Total Ankle Arthroplasty
  • CPT 23472 Total Shoulder Arthroplasty
  • CPT 23470 Shoulder Hemiarthroplasty

Finally, AAOS thanked CMS for responding to concerns regarding the Surgical Hip and Femur Fracture Treatment (SHFFT) model and for decreasing the number of mandatory Metropolitan Statistical Areas (MSA) for the Comprehensive Care for Joint Replacement (CJR) model (read more in Advocacy Now online here). However, AAOS stressed that CJR should be voluntary in all MSAs until such time as public reporting and best practices have been identified. AAOS also noted that we look forward to the new voluntary bundled payment models that will be available for 2018.

Read the entire AAOS comment letter online here.