under Medicare Part A on a case-by-case basis if the documentation in
the patient's medical record supports the admitting physician's deter-
mination that the patient requires inpatient hospital care. CMS also
finalized its proposal to prohibit Recovery Audit Contractors from
denying hospital claims for patient status for TKAs performed in the
inpatient setting for 2 years. This will let providers establish patient
selection criteria to determine the most appropriate setting to perform
TKA.
• Bundled payment programs. A number of commenters suggested
that removing TKA from the IPO list will further complicate both the
CJR and the BPCI initiatives, bundled payment models that place
providers at financial risk for the full episode of care for TKAs origi-
nating in the inpatient hospital setting. Industry stakeholders, includ-
ing the American Hospital Association, expressed concern that
removing TKA from the IPO list could jeopardize the success of the
CJR and BCPI programs, as shifting healthier TKA patients to the out-
patient setting would significantly alter the risk profile of the remain-
ing patients receiving such procedures on an inpatient basis.
Commenters believed that such a change in patient mix could
increase the average episode cost of inpatient TKA episodes, thereby
jeopardizing a hospital's ability to generate overall savings under the
BPCI or CJR model.
In response, CMS says providers will need time to gain experience in
safely shifting TKA patients to the outpatient setting. CMS doesn't
expect a significant shift in TKA cases from inpatient to outpatient set-
tings before the end of the BPCI and CJR models (Sept. 30, 2018 and
Dec. 31, 2020, respectively). CMS plans to monitor the volume and com-
plexity of TKA cases performed in outpatient settings to determine if
further refinements to these models are warranted.
3 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • J A n U A R Y 2 0 1 8
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