AAOS February 6, 2018
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TKA Frequently Asked Questions Resource

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TKA Frequently Asked Questions Resource

Until recently, total knee arthroplasty (TKA) was included on the Medicare inpatient-only (IPO) list. In light of the removal of TKA from the IPO, AAOS is providing answers to some frequently asked questions. It will be updated continually, as questions arise. Please find the most up to date information on the AAOS website, here. For additional questions, please contact Dena McDonough, Manager of Payment Policy at mcdonough@aaos.org.

Q1: What does removal from the IPO mean?

A1: Medicare classifies a procedure as “inpatient-only” based, in part, on the expectation that a stay of at least two midnights would be medically necessary. CMS uses established criteria to review the IPO list on an annual basis for determining whether any procedures should be removed from the list. Medicare explicitly states that removal of a procedure from the IPO list does not require the procedure to be performed only on an outpatient basis. It simply allows for the possibility in appropriate instances. The removal from the IPO allows for both hospital outpatient and inpatient care. The procedure is still not approved for ambulatory surgery centers (ASC). Addition to the ASC-approved list is a separate decision that Medicare may revisit in the future.

Q2: What is the effect on TKAs by removal from the IPO?

A2: Removal of the TKA procedure from the IPO list allows for payment in either the inpatient setting or the hospital outpatient setting. Medicare still expects most TKAs to be performed on an inpatient basis. There is a small subset of patients that could appropriately receive outpatient TKAs. It is for this minority of patients that Medicare is removing the requirement of inpatient surgery. Providers will continue to be required to document the reason for inpatient status, but that documentation need not be any different from what has been required for the past few years. There is no need to justify why a procedure is not being performed as an outpatient. We have heard of some issues surrounding preauthorization for Medicare Advantage (MA) patients. There seems to be a forceful push to default TKAs to the outpatient setting, assuming many cases will, ultimately, be converted to inpatients. Unfortunately, CMS allows MA discretion in coverage determination. We will continue to push for CMS intervention on minimum coverage standards.

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