July 12, 2018

No OPPS Rule Yet, so Let’s Talk Total Knee Replacement – Again

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If there is a pattern of inappropriate denials, report it to your CMS regional office

 Are all of you refreshing your browser every 15 minutes waiting for the Centers for Medicare & Medicaid Services (CMS) to release the Outpatient Prospective Payment System (OPPS) proposed rule?

I didn’t think so. But I am. Because I know that as soon as it is released, Chuck Buck, the RACmonitor publisher, will be asking me if I would write an article summarizing the important points.

Oh sure, Chuck, let me just whip through those 2,000 pages and find the 10 that actually matter.

Now, before anyone thinks I am being serious, let me be clear: almost every time Chuck asks me for an article, I have already started writing. And every article I write allows me another opportunity to fulfill my main goal: educating all of you.

Now, what’s new for this week, since I don’t have a new rule to discuss? Well, I was contacted last week by a hospital that had one of their Medicare total knee replacements denied as part of the short stay probe-and-educate initiative. This was a patient on 10 medications with multiple medical issues that were all well-delineated in the history and physical, from the surgeon himself. The doctor even documented that “given his medical comorbidities, he would be more appropriate for an inpatient procedure.” Fortunately, and despite the higher risk, the patient did well and went home the next day. The admission was denied.

Now, at this point I must tell you that I did not participate in the education call and have not yet seen the denial letter, but I know and trust the case management director to be telling me the truth. She tells me that the physician from Livanta, an emergency medicine physician, said that it didn't matter if the patient met Interqual criteria or what the doctor documented, because CMS doesn't want to pay Part A for one-midnight stays.

This makes no sense at all. We all know that in 2016, CMS adopted the case-by-case exception for patients who require inpatient admission despite an expectation of less than two midnights. This patient, with multiple medical problems that increase surgical risk, certainly fits that exception, and the medical record even has the orthopedist documenting that inpatient admission is warranted.

Additionally, in the July 2 issue of the Report on Medicare Compliance, Nina Youngstrom reprinted an actual denial of a total knee replacement from Livanta, and their templated wording states that the admissions in question were denied because “the documentation at the time of admission did not support the reasonable expectation of a two-midnight hospital stay, nor was there documentation of complex medical factors that would require the patient needing inpatient care despite not meeting the two-midnight benchmark.” That’s right; Livanta itself, in its denials states that CMS does allow inpatient admissions for one-midnight stays.

This hospital plans to appeal their denials, and I agree. The Livanta physician reviewer is absolutely wrong. Many hospitals have adopted the philosophy that the Quality Improvement Organizations (QIOs) cannot be trusted to actually follow CMS guidance, so they are performing all knee replacements as outpatient and then admitting if a second midnight is needed. I don’t think that is the right thing to do. If the QIO reviewers are misinterpreting the regulations, they should be held accountable. Hospitals should cite the regulations and Livanta’s own words in their discussions and appeals. If there is a pattern of inappropriate denials, report it to your CMS regional office, with the names of the QIO reviewers and PHI-free details of the case and a summary of the improper interpretation of the regulations. It makes no sense to give up compliant revenue because the QIO can’t get things right.

Is there anything you can do to try to avoid these denials? I think the best thing you can do it is hand the reviewer all the information they need to approve the admission on a silver platter. In the case of Medicare total knee replacement with an anticipated one-midnight stay, the history and physical should not just list comorbid conditions, but state the status of each, such as “poorly controlled” or “requiring multiple medications for control.” Then an explicit statement should be included noting that the comorbidities increase the patient’s perioperative risk and that inpatient admission is therefore warranted.

Linda H., the corporate utilization administrator for a Midwest health system, has created an excellent template for doing this. The template starts with “admission as an inpatient is reasonable and necessary due to increased risk of surgery due to the factors indicated below.” You can find the whole template on my webpage, http://www.ronaldhirsch.com/total-knee-replacement.html. Scroll down and click on “My Favorite Template for TKR Status.”

Ronald Hirsch, MD, FACP, CHCQM

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays.

The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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