BREAKING: Problems Plague Latest CMS TKA Memo

Errors persist in another communication on a key knee procedure.

Sixteen days after the original MLN Matters publication titled “Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule” was released, it was reissued today with clarifications. If you’re not aware why it was rescinded in the first place, read my Jan. 11 article here.

1. Unfortunately, there continue to be issues in the newest version.  In the first cited case, the patient undergoes an elective TKA and is placed into observation after receiving routine post-operative care. This should be held up as an example of incorrect placement into observation, not passed off as an appropriate first point in the case summary. There is no reason for observation here! It even states in the “rationale for approval” section of this case that there were no intraoperative complications, so we know that’s not what could have supported observation. When the patient started having issues, the morning of post-op day one, then placement of an observation order was appropriate. Later in the day, when it was clear that the patient’s condition would require continued hospitalization past a second midnight, we all agree that a change to inpatient was then appropriate, as well.

   Conversely, there’s the consideration of this patient’s past medical history. While we don’t have a lot of details, diabetes mellitus (depending on the level of control), arrhythmia, sleep apnea, and possibly chronic opioid use giving her chronic pain all might place this patient square in the category of “high risk” from the start. Perhaps she was appropriate for inpatient status solely based on that? Or is this a clue from the Centers for Medicare & Medicaid Services (CMS) that none of that past medical history qualifies a patient as high risk? We just don’t know.

2. In the second case, the patient was placed into inpatient status due to the development of post-operative bradycardia. But in the first version of the MLN Matters publication, this same patient was mentioned in the third-referenced case, and he was placed into inpatient status from the get-go due to his “extensive cardiac history.” My complaint at that time was that we didn’t receive strong guidance about what specifically qualified the patient as high risk, warranting inpatient status. Now, it looks like the patient isn’t considered high risk at all because he didn’t fit the criteria for inpatient care until the post-op bradycardia developed. What are we supposed to think now?

   Let’s also consider the idea of admitting a patient into inpatient status solely for bradycardia, even with a cardiac history. If this situation happened on post-op day one and a second midnight was anticipated/planned due to the need for continued monitoring/management in the hospital setting, then of course, inpatient care would be appropriate. But, on post-op day zero? Who’s to say that this patient’s rhythm wouldn’t normalize by the following day? Why would two midnights be anticipated immediately? I don’t think a scenario like this can reasonably be assessed to require at least two midnights of care. If CMS feels it can, does that mean every patient admitted from the emergency department with bradycardia and a cardiac history should be placed into inpatient status? Because CMS feels the admitting provider should reasonably anticipate two midnights? I can’t imagine that’s the case.

3. I said this before, and I want to emphasize it again: the third case is extremely misleading, and does not jibe with the direction about determination of status as initially given in the 2018 Outpatient Prospective Payment System (OPPS) Final Rule, when TKAs came off (IPO) list, reading that “CMS continues its longstanding recognition that the decision to admit a patient as an inpatient is a complex medical decision, based on the physician’s clinical expectation of how long hospital care is anticipated to be necessary, considering the individual beneficiary’s unique clinical circumstances.” The emphasis is on how long hospital care is anticipated to be necessary. If determination of status for TKAs (or in any other scenario, when considering the case-by-case exception) also can involve “unique clinical circumstances,” then this guidance should be reworded as “CMS continues its longstanding recognition that the decision to admit a patient as an inpatient is a complex medical decision, based on the physician’s clinical expectation of how long hospital care is anticipated to be necessary or based on consideration of the individual beneficiary’s unique clinical circumstances.”

Will we see a third version of this MLN matters? Unfortunately, I doubt it. Does this MLN Matters help us at all with the topic at hand? Nope, not as far as I’m concerned.

Click here to view the latest version of Total Knee Arthroplasty (TKA) Removal from the Medicare Inpatient-Only (IPO) List and Application of the 2-Midnight Rule.

Program Note:
Listen to R. Phillip Baker, MD report on this developing story on Monitor Monday, Jan. 28, 10-10:30 a.m. EST.