By the time total hip arthroplasty (THA) is off the inpatient-only list (IPO) on Jan. 1 and falls under the two-midnight rule—assuming CMS finalizes this provision in the outpatient prospective payment system (OPPS) regulation announced July 29—hospitals will have had two years to get used to the general idea because total knee arthroplasty (TKA) made the shift in January 2018. The two procedures have a lot in common in terms of the thinking and documentation that go into admitting a patient. If hips go the way of knees, not much may change, however, because CMS said 82% of TKAs were performed on inpatients in 2018. But more procedures generally are ambulatory, a trend that probably will accelerate, and CMS expects outpatient to be the default. Since many surgeons discharge THA patients on the same day as surgery or the next day, it may look like gaming if they suddenly change patient status, unless there’s a good reason to use the case-by-case exception.
“If your routine is the majority of hips go home the same day, you can’t take advantage of the inpatient admission option,” said Ronald Hirsch, M.D., vice president of R1 RCM, at an Aug. 13 webinar sponsored by RACmonitor.com.
THA will be approached the same way as TKA at Self Regional Healthcare in South Carolina starting Jan. 1, if CMS finalizes its plans, says Phillip Baker, M.D., medical director of case management. The patient-status decision turns on whether the patient is medically complex and requires post-acute care in a skilled nursing facility or inpatient rehabilitation facility. TKA patients, and soon THA patients, will be seen at the hospital’s pre-hab clinic before their procedures, Baker says. The pre-hab clinic, which is at a hospital-owned orthopedic practice, helps identify whether patients should have the procedure as inpatients or outpatients and prepares them for the surgery. “Where patients are likely to go [after surgery] is the most important question we ask,” he explains. “If they have trouble with pre-hab, we start them as inpatient.” If patients can be discharged home with outpatient therapy, the pre-hab clinic looks at the home care environment. For example, are there family members to help them? Can they stay on the first floor of their home and avoid stairs? Will the doors accommodate a rolling walker? All these factors go into the patient status decision. “It’s worked well for knees,” he says. The 2020 proposed OPPS regulation would also allow TKA to be performed in ambulatory surgery centers.
