Becker's Spine Review

24 PRACTICE MANAGEMENT 'An unprecedented amount of confusion' — Orthopedic society criticizes CMS for TKA final rule By Eric Oliver T he American Association of Hip and Knee Surgeons recently issued a posi- tion statement on the 2018 Medicare Outpatient Prospective Payment System rule that removed total knee arthroplasty from Medicare's inpatient-only list. e society noted while CMS removed TKA from the inpatient-only list, the agency did not allow the procedure to be performed in freestanding ASCs, which denotes a desire to move slowly when concerning TKA. e so- ciety believes CMS expected a large majority of TKA procedures would continue to be per- formed in an inpatient setting. "Unfortunately, the unintended conse- quence of this change has been an unprec- edented amount of confusion on the part of a variety of stakeholders regarding how to interpret this new rule. Hospitals, surgeons, and payers are interpreting the rule from different perspectives and as such are each coming to very different conclusions," the society said in a statement. Confusion is apparent when billing for the procedure. A reinterpretation of the two-midnight rule is creating confusion be- cause CMS treats some cases spanning less than two midnights as inpatient procedures, if a patient's record contains documentation of need. Traditionally, a case is inpatient if a patient stays for more than two nights. e society believes the current rule is being misinterpreted by parties requiring docu- mentation of medical need. Documentation of medical need is not required in all cases, but in select cases. e society also chastised pressure placed on physicians to make outpatient the default des- ignation for a patient prior to surgery, espe- cially in cases where one midnight for recov- ery is sufficient, but the patient is "clearly not [an] acceptable outpatient candidate." AAHKS issued three pillars of guidance for its members. 1. Expect the vast majority of patients to be treated, by default, as inpatient. e group argues, "e physiology of patients did not change, nor did the standard of care, from December 2017 to January 2018." 2. Hospitals, physicians and payers should agree the burden of proof is on the physi- cian to state what criteria are present that suggest inpatient resources should not be utilized. 3. AAHKS encourages its members to use outpatient designation, when doing so will not increase adverse event risk. "To only utilize an outpatient designation for a patient when doing so does not pose the risk of making the occurrence of, or failure to detect, such an adverse event more likely." n Ortho Rhode Island surgeon spearheading initiatives to combat opioid epidemic: 5 highlights By Mackenzie Garrity P rovidence-based Ortho Rhode Island surgeon Michael Bradley, MD, and anesthesiologist Henry Cabrera, MD, are rolling out a new pathway to curb opioid dependency at South County Health Orthopedics Center in Washington County, R.I. Drs. Bradley and Cabrera stress the idea of reducing and managing a patient's pain over eliminating a patient's pain. Here are five highlights. 1. Dr. Bradley describes the processes as a four-part path- way or a multimodal attack on pain. 2. Green Line Apothecary, a full-service pharmacy, is the first pathway stop. Three days prior to surgery, patients go to the pharmacy to pick up a blister pack of pre-ordered medication. Each pack contains acetaminophen, meloxicam (a nonste- roidal anti-inflammatory drug), gabapentin (a neuropath- ic pain pill), omperazole (a proton pump inhibitor) and tranexamic acid (a blood clotting medication). 3. Next, patients enter the intraoperative step. Instead of using a general anesthetic, the physicians use a spinal anesthetic to decrease the number of narcotics a patient needs post-surgery. 4. The post-operative stage addresses the various drugs patients are given between the time they are discharged from the recovery room and discharged from the hospital. Dr. Bradley recommends controlling a patient's pain with non-narcotic options first to reduce nausea and other ad- verse side effects. 5. Drs. Bradley and Cabrera recently added a fourth step for post-discharge. This addresses a patient's comfort from when they leave the hospital to around a week later. n

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