The Total Knee Arthroplasty Controversy Gets (Even More) Confusing

“Outpatient” does not equate “same-day.”

By this time last year, the Centers for Medicare & Medicaid Services (CMS) had notified providers that they were removing total knee arthroplasty (TKA) from the Medicare inpatient-only list. While the cries of disbelief and howls of frustration eventually died down after a few months, the remainder of 2018 has continued to be a confusing year. But, just when I thought things might level out as we approach 2019, the American Association of Hip and Knee Surgeons (AAHKS) released a position statement entitled “Outpatient Joint Replacement.”

Much of the discussion in this position statement is significant, stressing the importance of patient safety, proper patient selection, and financial transparency. In fact, AAHKS goes as far as recommending to surgeons that they disclose any potential financial conflicts of interest related to ownership of the ambulatory surgery center, outpatient center, or distributorship. However, in the midst of ongoing confusion over which Medicare patients can be hospitalized as inpatient and which should be outpatient, the terminology used by AAHKS creates additional uncertainty.

In the introduction to the statement, AAHKS states, “Hospitals, surgeons and payers have recognized the potential benefits to patients that derive from decreasing the length of inpatient hospital stay after total hip and total knee arthroplasty, and even the potential benefits associated with same-day discharge in the outpatient setting for select patients. Further, with the Centers for Medicare & Medicaid Services’ (CMS) recent decision to remove total knee arthroplasty from the Medicare inpatient-only list, future demand for same-day outpatient discharge for hip and knee arthroplasty is likely to increase.” They go on to say, “This position statement is intended to clearly state our priority of preserving patient safety and to outline specific recommendations for surgeons and institutions considering discharge of hip and knee replacement patients on a same-day outpatient basis.”

At face value, these statements stressing careful patient selection appear reasonable. But the statements, and others, also appear to equate outpatient surgery with same-day discharge. In other words, AAKHS implies that if a patient undergoes surgery as an outpatient in any location, the expectation should be that the patient will be discharged later that same day. And, while this is true for an outpatient surgery in an ambulatory surgery center, where the regulations require that the patient should not be expected to require care past midnight (42 CFR 416.166), this is not the case for an outpatient surgery performed in a hospital.

When a patient covered by Medicare has surgery performed as outpatient in a hospital, that patient may remain in the hospital overnight as an outpatient for their routine recovery following the surgery, with discharge taking place any time on post-op day one. While some orthopedic surgeons are not accustomed to this, other surgical specialists have been following this process for many years with surgeries such as cholecystectomies, mastectomies, transurethral prostate resections, and hysterectomies. In addition, cardiologists have also done this for years with scheduled cardiac interventions such as stenting, pacemaker placement, and defibrillator placement. Inpatient admission is warranted only for patients who specifically meet the requirements of the Two-Midnight Rule with its many nuances.

Commercial insurers also allow outpatient surgery patients to spend the night as part of their normal recovery if it is deemed necessary by the surgeon. As such, they consider routine recovery services included within the payment for the surgery itself. Rarely will they allow a patient whose recovery is expected to be one day to be admitted as inpatient. In fact, many commercial insurers will “allow” that outpatient surgery patient to remain outpatient for several days post-operatively if their recovery is simply slower than expected.

While I appreciate the efforts of the AAHKS to advocate for both patients and surgeons, their unfortunate use of “outpatient” and “same day” as synonyms is only going to contribute to ongoing confusion among their members. I believe the AAHKS should retract their position statement and revise it to clearly differentiate between outpatient surgery at a hospital, where routine recovery can include an overnight stay, and outpatient surgery at an ambulatory surgery center, where the patient should be expected to discharge the same calendar day.

The expectation of overnight recovery in a hospital makes these two types of “outpatient surgeries” significantly different. And, it is clear there is a clinical differentiation between the patient who can undergo outpatient surgery in a hospital from a patient who can undergo outpatient surgery in an ambulatory surgery center.

Despite our best efforts, we have been unable to get the regulations changed, which leaves changing the position statement as the only viable option.


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Juliet Ugarte Hopkins, MD

Juliet B. Ugarte Hopkins, MD is President of the American College of Physician Advisors and former 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 and was also medical director of pediatric hospital medicine and vice chair of pediatrics at a hospital in northern Illinois. She was the first physician board member for the Wisconsin chapter of the American Case Management Association (ACMA), is a current member of the RACmonitor editorial board, makes appearances on Monitor Mondays, contributes to ICD10monitor, and is a national speaker.

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