News Alert: CMS Stance on Total Knee Replacement Sparks Protests from Surgeons

Orthopedic surgeons are upset with various interpretations of regulations on total knee replacement coming from CMS.

The saga of determining the proper status for Medicare total knee replacement (TKR) patients continues.

As many people know, you do not want to upset a surgeon. And it appears that the Centers for Medicare & Medicaid Services (CMS) did just that. In fact, I’d say that CMS upset every orthopedic surgeon in the country, because a letter was sent to Seema Verma, the CMS administrator, signed by the American Academy of Orthopedic Surgery (AAOS), the American Association of Hip and Knee Surgeons, The Knee Society, The Hip Society, and 35 other state and regional orthopedic societies. In that letter, they were very clear that they are not happy with the many interpretations of the regulation and the resultant confusion of the 34,000 orthopedic surgeons they represent.

Stephen Sokolyk, MD at Texas Health Resources, explained the problem well: he works with orthopedists who only do hip and knee replacement. That means until this year every surgery they did was inpatient-only. So when he tried to explain that the change means that the status of a knee replacement patient would now be viewed the same way they’d view a fracture of the arm needing surgery, the doctors found it “humorous,” because they don’t treat fractures. So he had to keep it as simple as possible.

But as we all know, the regulations are far from simple and the answers given on the recent Open Door Forum (ODF) did nothing to clarify that. The AAOS has asked CMS to develop clear criteria for status, and AAOS continues with their position that outpatient TKR procedure would be appropriate only for carefully selected patients who are in excellent health, with no or limited medical comorbidities, and who have sufficient caregiver support.

The AAOS is also calling on CMS to intervene with the Medicare Advantage plans and their inconsistent status determinations. The AAOS is very concerned with the impact that this change has on the bundled payment programs, as this will have significant adverse financial effects on both physicians and hospitals, as I laid out in a past RACmonitor article, and AAOS made several proposals to alleviate that. It appears CMS is at least listening to them. In the letter, AAOS references that they have had several teleconferences with CMS while the rest of us have had to rely on the one ODF and a lot of speculation.

It was also reported that a CMS medical officer spoke at a recent American Health Lawyers Association meeting. Marjory Cannon, MD, a CMS medical officer in the division of Beneficiary Healthcare Improvement and Safety, addressed the rumors that because of the removal of TKR from the inpatient-only list there will be an increase in denials of claims.“I wanted to dispel that misconception,” Dr. Cannon reportedly told attendees.

That statement reassures me that CMS is well aware that this remains a big mess and they are not going to take any audit action until things settle down and get sorted out.

I think all this gives more support to the stance advocated in my past RACmonitor article and webcast, and what you will be hearing if you attend the upcoming webcast with Mary Beth Pace and Jeff Pilger, MD.

While I talk the talk, Ms. Pace and Dr. Pilger walk the walk. And you can learn the walk too.

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Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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