The 2020 proposed Outpatient Prospective Payment System (OPPS) rule will remove THA from the inpatient only list. In 2018, it removed TKA from the inpatient only list.
This does NOT mean TKA/THA cannot be inpatient. It means that inpatient admission must be supported by documentation of medical necessity. In fact, the American Association of Hip and Knee Surgeons noted in their position statement on the removal of TKA from the inpatient only list, “Although TKA has been taken off the IPO list, it is reasonable to expect that the vast majority of patients should be treated, by default, as qualifying for inpatient designation.”
Generally, the patient will need 2 midnights of hospital level services plus medical necessity. Rarely, on a case-by-case basis, patients with < 2 midnights will qualify for inpatient level of care if there is adequate medical necessity documented in the record. CMS reported that inpatient status is a complex medical judgment made by the physician based on the beneficiary’s individual clinical needs and must be clearly and completely documented in the medical record.
Download the complete tip, TKA-THA Medical Necessity.