CMS issues guidance on applying the 2-midnight rule to TKA

CMS recently reissued Special Edition MLN Matters 19002 to address lingering provider questions surrounding the application of the 2-midnight rule to total knee arthroplasty (TKA) claims. The MLN Matters article was originally released January 8 but was reissued January 24 to correct errors.

TKA was removed from Medicare’s inpatient-only list effective January 1, 2018, leading many providers to question how best to determine when a TKA case was appropriate for inpatient hospitalization and whether inpatient TKA claims would be more likely to be audited. CMS does not intend removal of TKA from the inpatient-only list to dictate that all TKAs must be performed on an outpatient basis, according to the article. The agency has no default determination and recognizes that the decision to admit a patient as an inpatient is a complex medical decision based on the individual patient’s unique clinical circumstances and the physician’s expectation of how long hospital care is excepted to be necessary. CMS contracts with Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIO) to review a sample of short-stay inpatient claims for compliance with the 2-midnight rule. Although TKAs are now subject to BFCC-QIO review, contractors do not target condition or disease-specific claims for review.

The article explains that for short-stay TKA claims that are selected for BFCC-QIO review, the reviewers will look for documentation that shows the admitting physician’s reasonable expectation that the beneficiary requires medically necessary hospital services that will span two midnights or longer, or the admitting physician’s judgment that inpatient hospital care was medically necessary despite not meeting the 2-midnight benchmark. The latter case-by-case determination should be based on complex medical factors including the:

• Patient’s history, comorbidities, and current medical needs
• Severity of signs or symptoms
• Risk adverse events

The article goes on to describe three example cases and the rationale for why they would or would not be appropriate for inpatient admission. The article also includes five FAQs and a list of additional resources. The guidance is effective January 1, 2018.