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Published on January 09, 2018

NKCH Poised to Work Within CMS Total Knee Ruling

Ruling Affects Seven CPT Codes

In addition to total knee arthroplasty (CPT® 27447), the Centers for Medicare & Medicaid Services hospital outpatient prospective payment system ruling removed five other procedures:

  • 43282 – Laparoscopic repair of paraesophageal hernia with implantation of mesh
  • 43772 – Laparoscopic removal of adjustable gastric restrictive device
  • 43773 – Laparoscopic removal and replacement of adjustable gastric restrictive device
  • 43774 – Laparoscopic removal of adjustable gastric restrictive device and subcutaneous port
  • 55866 – Laparoscopic/
    robotic retropubic radical prostatectomy

CMS also added one procedure to the inpatient-only list: CPT 92941, percutaneous transluminal revascularization of total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft.

When the Centers for Medicare & Medicaid Services recently issued the hospital outpatient prospective payment system for 2018, the ruling included the removal of total knee arthroplasty from the inpatient-only list. Although patients now fall under a different length of stay expectation, North Kansas City Hospital physicians have long sought to reduce patient hospitalizations. The ruling, which applies to individuals with Medicare fee-for-service coverage, went into effect Jan. 1.

Length of Stay Considerations

“It’s not a surprise that Medicare would see the value in patients being short-stay after knee replacement. We’ve been working toward short stays for a long time. We understand that patients do much better when they rehabilitate and get back to their home environments quickly,” said Steven B. Smith, MD, an orthopedic surgeon with Northland Orthopedics & Sports Medicine.

Although the two-midnight expectation now applies because the surgery is no longer on the inpatient-only list, physicians need not worry about what this means for their patients who require longer hospital stays. “If it’s medically necessary, patients can be converted to inpatients before the second midnight,” said James L. Stewart, MD, CHCQM, North Kansas City Hospital’s medical director of Case Management.

Patients could stay a second midnight if, for example, they experience uncontrolled pain, nausea and vomiting, or need to remain on IV fluids postoperatively. Dr. Stewart noted that although most patients return home on day two, those with extenuating circumstances who need to move to a skilled nursing facility require three consecutive midnights in the hospital under Medicare FFS.

He added one caveat: For this Medicare population, total knee arthroplasties performed at an ambulatory surgery center still are not allowed.

Breadth of Care

Total Knee ReplacementBecause of their postoperative or orthopedic conditions, some patients aren’t candidates for rapid recovery. “At North Kansas City Hospital, we care for a breadth of patients – those who are capable of an accelerated recovery and those who are going to take longer,” Dr. Smith said, adding that bringing everything together in a collaborative pre- and postsurgical approach among nursing units, physical therapy, case management, anesthesia and orthopedic staff is paramount.

For patients requiring longer hospital stays, staff use pain management and rapid therapy techniques, including minimizing IV narcotics and nerve blocks, to speed recoveries and allow patients to move around more quickly after surgery.

“When patients have very low levels of pain postop, they can move and put weight on their knees more quickly, and the muscles and soft tissues all wake up and respond to activity better,” Dr. Smith said. “We also minimize the risk of oversedation, pneumonia and blood clots due to immobility.”

Patient Feedback

Looking back on how recovery from knee surgery has advanced in just the last 10 years, Dr. Smith recalled the dramatic feedback patients have shared on follow-up visits.

“Very little has changed about the operation, but a lot has changed with how we treat patients around the time of surgery,” Dr. Smith said. “It’s almost universal that they are pleasantly surprised by how much less discomfort they have and how quickly they recover and gain mobility.”


Steven B. Smith, MD

Steven B Smith, MDDr. Smith earned his medical degree from the University of Iowa Carver College of Medicine. He completed his orthopedic surgery residency at Indiana University Medical Center.

James L. Stewart, MD, CHCQM

James L Stewart, MDDr. Stewart earned his medical degree from Saint Louis University School of Medicine. He completed his residency at the University of Kansas Medical Center.