Effective 1/1/2020, Medicare pays for Knee Replacement Surgery in the Ambulatory Surgery Center (ASC)

CMS has finalized the addition of eight codes to the ASC-payable list, including total knee arthroplasty (TKA), which were previously not payable in the ASC setting.

CMS has finalized the addition of the following eight codes to the ASC-payable list beginning January 1, 2020. These codes are:

  • 27447 (Total knee arthroplasty – with or without robotic-assistance)
  • 29867 (Surgical arthroscopy of the knee with allograft implant)
  • 92920 (Percutaneous transluminal coronary angioplasty; single major coronary artery or branch.)
  • 92921 (Percutaneous transluminal coronary angioplasty; additional major coronary artery or branch.)
  • 92928 Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch.)
  • 92929 (Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; additional major coronary artery or branch)
  • C9600 (Percutaneous transcatheter placement of drug eluting intracoronary stent(s), with coronary angioplasty)
  • C9601 (Percutaneous transcatheter placement of drug-eluting intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (list separately in addition to code for primary procedure)

With regards to TKA, it is important to note that based on the public comments CMS received, the Agency is not finalizing any of the additional requirements on which they sought comment, such as adding a modifier or requiring an ASC to have a certain amount of experience in performing a procedure before being eligible for payment for performing the procedure under Medicare.

Maria K Todd, MHA PhD | AskMariaTodd™

We spoke with Maria Todd of AskMariaTodd™, an expert with more than 3 decades of contracting with employers and health, travel assistance and workers comp insurers for bundled price surgeries around the USA and abroad.  Here’s how she explained what’s happening. 

Why the change in health policy after so many years?

“The Center for Medicare and Medicaid Services (CMS) was requested to review their stand on only paying for knee replacement surgery (total or partial knee arthroplasty) in the hospital setting. Meanwhile, ambulatory surgery centers (ASCs) have proven over the years that the setting is generally safe and not detrimental to care quality or patient safety, or at higher risk for complications because the procedure is performed in the ASC setting. 

Typically, the ASC setting is 60% (or higher) less costly for the same surgeon, same implant, same procedure than its hospital counterpart. For years, hospitals have had the stranglehold on this procedure and patients have had to pay more than necessary because by American health policy, the surgeon was forced to perform the arthroplasty (replacement) at the hospital instead of in an ASC setting. Hospitals made strategic decisions based on this site of service restriction for knee and hip replacement surgery and for the past several years have been buying orthopedic practices or hiring orthopedic surgeons as employees so that the hospital was assured the referral stream for these high-reimbursement procedures. 

Of interest to patients

For patients, what this change means is that patients will have more choice, will likely not pay more for that choice, and may face lower risk of hospital-acquired infections in the ASC setting, and notice more nursing attention in the ASC setting because there are fewer cases ongoing simultaneously as compared with the hospital setting. Their patient experience in the ASC is often much more enjoyable than in the hospital but previously they didn’t have the choice to find out if they were a Medicare beneficiary.

Watch What Happens Next in Physician Hospital Employment and Practice Acquisition Trends

Now that this party is over and, several cardiac procedures are also approved for the ASC setting, I predict that the hospitals will over the next year begin to terminate or allow employment contracts to expire without renewal for employed orthopedic and cardiac surgeons. For those who shut down a lucrative and existing practice, they will be out on the street and have to start over from scratch if the hospital bought the “assets” of the practice including all the patient records and patient accounts at the time of the acquisition.”

If this turns out as I predict, the hospitals won’t pay a severance lump sum. They may simply give notice of intention to not renew. That means that the surgeons will be left to restart a new practice with cash in hand or loans to purchase equipment they’ll need from imaging to casting, braces, supplies, medications and more. They will be forced to find a new office space, hire new staff, including an assistant, front desk, insurance biller, billing software, EHR, and more. They will need new collection agencies, telehealth software, and more.Their employment contracts may stipulate that they relocate a certain distance away from their current workplace and that they cannot contact existing or former patients to announce the new situation. Some of those restrictions may be set aside if the contract allows for it, but in many cases, the doctors didn’t do a good enough job on exit strategy when they agreed to the employed gig.

During much of my 35+ years in my professional career as a health administrator and independent consultant to the healthcare industry, I’ve watched this trend of employing surgeons through direct hire and practice acquisition and then unloading them when the trend reversed several times. It is very disheartening to see doctors in their 40s and 50s have to start over as if they just completed residency or fellowship. There is also interest from private equity in buying and forming new orthopedic group practices with ancillary services in place, but that setup can be tricky depending on state law and corporate practice of medicine (CPOM) doctrine, Stark Laws, and restrictions on who can be a shareholder in a medical corporation.”

For surgeons displaced from their hospital employment, Todd suggests maintaining hospital privileges but relocating as close as possible to an accredited ASC licensed for overnight stay at a location lower than 4000 feet above sea level. Seek out ASCs that market cash pay surgery case rates, feature zero-interest patient medical financing without recourse, and are interested in or active in domestic medical tourism and contracting directly with employers and TPAs for bundled case pricing. That essentially describes the mainstay of ASCs we work with at SurgeryShopper.com, so call us from some options and ideas if you like. Dr Todd also offers independent physician consulting if you need to re-establish a traditional or concierge or direct pay (cash) practice. She can be reached at (800) 727.4160 and she offers a complimentary 15 minute telephone discussion for new clients.

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