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The action by CMS to remove total knee replacement from the inpatient-only was not unexpected in the 2018 OPPS final rule released on Wednesday. 

In a surprised move the Centers for Medicare and Medicaid Services (CMS) released the Outpatient Prospective Payment System (OPPS) final rule Wednesday rather than on Friday as the agency has done in the past. But as expected, CMS did finalize their proposal to remove total knee replacement from the inpatient-only list. 

Unfortunately, CMS did not provide any useful guidance on how a physician should determine which patients qualify for inpatient admission, referencing instead their standard statement that it “is a complex medical judgment made by the physician based on the beneficiary’s individual clinical needs and preferences.” 

CMS also removed laparoscopic and robotic prostatectomy from the list, as the agency had proposed but also, unexpectedly, removed four gastric laparoscopic procedures CPT® 43282, 43772, 43773, 43774. 

Even more surprisingly, and with little comment, CMS added CPT 92941, Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, to the inpatient-only list. This move should provide hospitals that treat patients with acute myocardial infarctions very efficiently with a bit of relief knowing that they can always be admitted as inpatient. 

Additional updates to follow.

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Ronald Hirsch, MD, FACP, 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, 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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