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I am changing my interpretation of the final rule with help from the trenches.

Often referred to as the “carpenters” of medicine, orthopedic surgeons are not well-known for deep contemplation of Centers for Medicare & Medicaid Services (CMS) rules. But I’ll be damned if I haven’t had to wrestle with two profound concerns some of mine have brought to my attention. I’ll detail one of them here, and stay tuned for an upcoming article detailing dilemma No. 2.

Unlike the more common debate surrounding admission status, our current struggle involves placement into a Skilled Nursing Facility (SNF). It started with the following from the 2018 Outpatient Prospective Payment System (OPPS) Final Rule: “Numerous commenters…believed that TKA met CMS’s established criteria for removing a procedure from the IPO list…(and) appropriately selected patients…in excellent health and with no or limited medical comorbidities and sufficient caregiver support (who) could be successful candidates for outpatient TKA.”

Wait…what? Since when has “insufficient caregiver support” made a patient appropriate for inpatient status? That’s right – never. But, then there it was again: “…we expect that physicians will…exercise their complex medical judgment, based on a number of factors, including the patient’s comorbidities, the expected length of stay in the hospital…the patient’s need for postoperative skilled nursing care, and other factors” (bold emphasis mine).

So, there we were, seemingly encouraged by CMS to place a patient into inpatient status if there was a plan for SNF following a TKA. This went against everything we knew, but it seemed the Final Rule changed all that, and I advised my orthopedic surgeons accordingly.

Three months later, I am changing my interpretation of the Final Rule, with their help from the trenches. “The patient’s need for postoperative skilled nursing care” and “sufficient caregiver support” are the two portions of the Final Rule that are causing the most grief. At face value, they do seem to direct that a patient transferred to a SNF following discharge is appropriate for Inpatient status. But now, I think it comes down to a single word: need.

During conversations pre-op in the surgeons’ offices, it was relayed that some patients were truly expected to require SNF care, post-procedure. We were discussing elderly patients in multi-level homes who had prior issues with recovery following prior surgeries, often also having absolutely no family, close friends, or other social support to assist in the days following; the surgeons clinically believed that these patients would require care in a facility. But then there were other patients who unabashedly admitted that they had no intention of going home from the hospital. No matter how hard medical staff tried to convince them otherwise, they looked upon care in an acute rehab facility as a step up from recovering at home. Perhaps like entering a spa for a few days? Regardless, these patients made it clear that while they did have family who could assist them at home, they were not willing to ask nor make arrangements.

“Do these patients need SNF care?” the surgeons asked. Technically, no. These patients could safely discharge to home on post-op day one if their daughter or close friend across the street simply spent a day with them, and then was available to assist as needed for another couple of days. These patients do not need care in a SNF; they want care in a SNF. Thinking about this now, with the benefit of hindsight and time, I almost feel silly for not coming to this conclusion from the start. These patients, with their own pre-op plan of heading to a SNF after discharge, are not appropriate for inpatient status.

Then the surgeons told me about an even more frustrating scenario. Patients who go through the pre-op planning reporting, yes, they have made arrangements for someone to assist them at home when discharged, but then, what do you know? Post-op day one comes, and suddenly their daughter isn’t able to help. Or they change their mind and don’t want to ask anyone for assistance. These patients are ready for discharge, but not to be sent home alone. The patient will require a second midnight in the hospital before they can be safely discharged home alone with assistance and home PT/OT.

Does this mean a change to inpatient status is appropriate, given the two-midnight rule? Right now, my thought is no. These patients don’t need hospital care. They simply can’t be discharged home alone on post-op day one. If the patient paid for assistance at home out of pocket, or followed through with the original plan for family or friends to assist, continued hospitalization would not be required. For these patients, I believe our case managers will have the unenviable task of working with the patient to pay out of pocket for home services, pay out of pocket for transfer to a SNF, or deliver an ABN.

I hate retracting prior direction to my docs, but it is what it is. CMS may have given us over 5,000 words to explain TKAs coming off the Medicare inpatient-only list, but the details certainly are not clear-cut. I’m interested in hearing about other changes of heart my fellow physician advisors have had these past few months.

Please consider reaching out to me at Juliet.UgarteHopkins@phci.org to share your standpoint and direction to physicians!


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Juliet B. Ugarte Hopkins, MD, CHCQM

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, is a physician advisor for case management, utilization, and clinical documentation at ProHealth Care, Inc. in Wisconsin. Dr. Ugarte Hopkins practiced as a pediatric hospitalist for a decade. She was also medical director of pediatric hospital medicine and vice chair of pediatrics in Northern Illinois before transitioning into her current role. She is the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA), a member of the RACmonitor editorial board, and a member of the board of directors for the American College of Physician Advisors (ACPA). Dr. Ugarte Hopkins also makes frequent appearances on Monitor Mondays and contributes to ICD10monitor.

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