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Medicare Guidance on Patient Status for Total Joints

Thursday, January 25, 2018   (0 Comments)
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The FOS is concerned with reports from around that State that hospitals and insurance carriers may be more aggressively interpreting Medicare’s decision on outpatient joints than Medicare intended and stated in their Final Rule. Excerpts from Medicare’s Final Rule are included below.   It is clear to our organization that Medicare intended only a small percentage of total joints to be appropriate for the outpatient setting based on the beneficiaries clinical needs.   We do not feel it is appropriate for payers or hospitals to try to force all total joints into the outpatient setting.


We hope these excerpts below will assist you with ongoing dialogue with your local institutions and payers in relation to the appropriate status of your patients needing joint replacement surgery.    If you experience issues surrounding Medicare’s Final Rule on Total Joints, please make sure you reach out to our office. 


“As previously stated in the discussion of the CY 2018 OPPS/ASC proposed rule, we continue to believe that the decision regarding the most appropriate care setting for a given surgical procedure is a complex medical judgment made by the physician based on the beneficiary’s individual clinical needs and preferences and on the general coverage rules requiring that any procedure be reasonable and necessary… we believe that the surgeons, clinical staff, and medical specialty societies who perform outpatient TKA and possess specialized clinical knowledge and experience are most suited to create such guidelines.”


"We reiterate that removal of the TKA procedure from the IPO list does not require the procedure to be performed only on an outpatient basis. Removal of the TKA procedure from the IPO list allows for payment of the procedure in either the inpatient setting or the outpatient setting.”


“As mentioned earlier, we believe that there is a subset of less medically complex TKA cases that could be appropriately and safely performed on an outpatient basis. However, we do not expect a significant volume of TKA cases currently being performed in the hospital inpatient setting to shift to the hospital outpatient setting as a result of removing this procedure from the IPO list. At this time, we expect that a significant number of Medicare beneficiaries will continue to receive treatment as an inpatient for TKA procedures.”


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