When can we change to Inpatient status for outpatient surgical procedures like hip and knee replacements and others?

When can we make a hip surgery patient a full admission?

This question comes every day multiple times when we work for Utilization Reviews.

We know that for Calendar Year 2020, CMS removed Total Hip Arthroplasty [CPT code 27130] (Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft), six spinal procedure codes, and five anesthesia codes from the CY 2020 Outpatient Prospective Payment System [OPPS] inpatient only list.

CMS assigned the procedure to C-APC 5115 with status indicator “J1”.

CMS did not propose to remove partial hip arthroplasty [PHA/Hemiarthroplasty] from the IPO list because they continue to believe that it does not meet the criteria for removal.

Removing a procedure from Medicare’s FFS Inpatient Only List does not require the procedure to be performed on an outpatient basis. Rather, it allows the procedure to be performed in a hospital inpatient or hospital outpatient status

This means, we have to place these patients on Observation after total hip arthroplasty and not admit them as inpatient unless patient has some clinical factors as given below.

>Elderly patients with Age> 80yrs.

>ASA [American Society of Anesthesiologists] score of >=3, You can find this score in preop notes from the anesthesiologist.

American Society of Anesthesiologists (ASA) Physical Status Classification

  • Physical status I: Healthy patient
  • Physical status II: Systemic disease without functional limitation
  • Physical status III: Severe systemic disease with definite functional limitation
  • Physical status IV: Patient with severe systemic disease that is a constant threat to life
  • Physical status V: Moribund patient unlikely to survive 24 hours with or without an operation

>High risk for withdrawal for those patients with substance abuse history.

>Comorbid conditions like CAD, COPD.

>HTN with high BP, SBP more than 140, DBP more than 90.

>CVA or TIA within the last 3 months.

>if the patient is Obese with BMI>35 and lives alone at home and now needs rehab placement.

In general, for other surgical procedures also, the following clinical factors can support inpatient status.

>Open procedures requiring postoperative drains, further monitoring or therapy.

>Overall patient’s hemodynamic status.

>Urgency of the procedure.

>Stability of comorbid conditions like Diabetes Mellitus, Fluid status.

>Complications due to patients medical history like bleeding, electrolyte imbalance, thromboembolic events etc.

Even though CMS said that hip surgery patients should be outpatient, they can be inpatients depending on the patients overall condition for the calendar year 2020 and they may change the rules again next year.

The above points can “likely (but not necessarily)” support your decision for inpatient.

Utilization management nurses can run the scenario in Interqual guidelines software and check or a physician advisor can document the above factors in patient’s chart to support inpatient stay.

You can read Federal Register for further info.


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