In two weeks, total hip arthroscopy (THA) will be off the inpatient-only (IPO) list and inside the grayer zone of the two-midnight rule, which means hospital claims will be more dependent on orthopedic surgeons and what physician advisers say is their laconic documentation. That doesn’t bode well for supporting inpatient admissions for THA and total knee arthroscopy (TKA), which was removed from the IPO list almost two years ago, although many of them will move to the outpatient setting anyway, physician advisers say.
Whether THA and TKA patients will be admitted as inpatients depends on their comorbidities, surgery and anesthesia risks, and anticipated surgical challenges, assuming there is documentation to support them, said Lisa Banker, M.D., medical director of revenue integrity at CarolinaEast Health System in North Carolina. She works with orthopedic surgeons to get comorbidities in the medical record, “assuming I have a good enough conversation with them.” Partly because of the documentation challenges, her health system defaults to outpatient for TKAs “99% of the time” and will do the same for THAs, converting patients to inpatient if things change unless they are obviously admissions from the get-go.
Every hospital has to get comfortable with its approach to patient-status decisions, Banker said at a webinar sponsored by RACmonitor.com on Nov. 14.
“There’s no 100% right answer,” she said. “We are all asking the same questions: What is the safest place to be? What is safe with revenue, and what is safe with audit risk and denial defense? We are forced to live in the gray with these scenarios, because there is not a lot of guidance with these.”
The seismic shift for hips[1] came down in the final 2020 Outpatient Prospective Payment System (OPPS) regulation, which takes effect Jan 1. THA (CPT code 27130) is off the IPO list “for appropriate patients” and assigned to C-APC 5115 with status indicator “J1.” Patients may be good candidates for outpatient THA if they are a “relatively low anesthesia risk and without significant comorbidities who have family members at home who can assist them,” according to the regulation. Conversely, patients with multiple comorbidities “would more likely require inpatient hospitalization and possibly post-acute care in a skilled nursing facility or other facility.” This language mirrors what CMS released when it moved TKA off the IPO list.
