CMS Application of the “Two-Midnight Rule” to TKA Procedures
Following the announcement that total knee arthroplasty (TKA) is being removed from the inpatient only list in the most recent CMS CY18 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems (HOPPS) rule, AAHKS and our regulatory firm Epstein Becker & Green discussed with CMS Hospital and Ambulatory Policy Group staff interpretation of the “Two-Midnight Rule” for TKA procedures.
Medicare regulations state clearly that billing for an inpatient admission that lasts less than two midnights may be appropriate when it is the physician’s clinical judgement (as documented in the medical record) that the individual patient requires an inpatient admission, based on patient history, comorbidities, current medical needs, risk of adverse event. In addition, for a two-year transition period, CMS has suspended review by Recovery Audit Contractors of a hospital’s decision whether to bill TKA procedure as inpatient or outpatient. We will continue to work with CMS to clarify this issue. Review the Two-Midnight Rule Summary for more information.
AAHKS Position Statement on CMS Guideline Use of Antibiotics
The Centers for Medicare & Medicaid Services (CMS) released their 2017 Guideline for the Prevention of Surgical Site Infection, which recommends against the use of post-operative prophylactic antibiotics – including patients undergoing total joint arthroplasty (TJA). Full statement.
Quality Payment Program (QPP)/MACRA Payment Resources
With the repeal of the Sustainable Growth Rate (SGR) system, Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). On October 14, 2016, CMS released the final rule implementing the new Medicare physician Quality Payment Program (QPP) as authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The QPP incentivizes quality physician services through the Merit-based Incentive Payment System (MIPS) which adjusts Medicare reimbursement beginning in 2019 based on physician performance measured in 2017 and beyond. Physicians may be exempted from MIPS adjustments and may receive a bonus payment for participating in CMS-approved Advanced Alternative Payment Models (Advanced APMs). CMS made significant changes from the proposed rule. Learn more.
Cigna/eviCore Pre-Certification Resources
Cigna (through eviCore) has implemented a pre-certification process for total joint arthroplasty patients. AAHKS President Jay R. Lieberman MD, and AAHKS Executive Director Mike Zarski met with the leadership of Cigna and eviCore to review concerns with this process. The AAOS also had representatives at the meeting. AAHKS and AAOS expressed concerns with a number of procedural and clinical aspects of the pre-certification process. At that meeting, it was agreed there would be a follow-up conference call to address any problems encountered with the pre-cert process after the official roll-out.
If your staff has problems getting cases approved in a timely fashion, it is essential that that you make this clear to eviCore and Cigna. It is also essential that you inform AAHKS about your experience with the Cigna precertification program both good and bad, but especially denials or delays in authorization. AAHKS will then review this data with Cigna in late February or early March.
Please contact Josh Kerr, Director of Advocacy and International Activities, at AAHKS about your experience with Cigna or if you have any questions regarding this process at firstname.lastname@example.org or (847) 698-1200.
To access the Cigna/EviCore approval process, visit https://myportal.medsolutions.com or call 888-693-3297.
Visit the AAHKS ICD-10 Resource Center
AAHKS has compiled resources to assist physicians and their staff with ICD-10 transition. Full details.
Primer on Orthopedic Risk Stratification and Comorbidity Coding
The AAHKS Risk Adjustment Task Force has been working with CMS and the Yale Outcomes Group to improve the risk adjustment models used in TJA performance measures. We are seeking your help in systematically capturing the risk variables known to influence outcomes, and have developed an easy to use checklist to help record the data. Full details.
Reports from AMA Meeting Delegates
2015 AMA Interim Meeting
AMA Delegate Chris J. Dangles, MD and Joshua Kerr, AAHKS Director of Advocacy and International Activities, attended the AMA Interim Meeting in Atlanta and submitted this report.
2015 AMA Annual Meeting
Courtland G. Lewis, MD ended his term as delegate and chaired the Reference Committee G on Medical Practice at the 2015 Annual Meeting of the American Medical Association. Read the report.
Patient Risk Calculator for Surgeons
AJRR has developed this risk calculator for orthopaedic surgeons to use when advising Medicare-eligible patients (65 years or older) on their individual risk of poor outcomes for total hip and knee surgery.
Articles by AAHKS Corporate Partners
Orthopedic Service Line Optimization, Stryker Performance Solutions
Success in Bundled Payments for Care Improvement, Stryker Performance Solutions