CMS Adds Total Hip to ASC Covered List, Eliminates Inpatient Only List

By Carolyn LaWell

CMS Adds Total Hip to ASC Covered List, Eliminates Inpatient Only List

In finalizing its payment rules for 2021, the Centers for Medicare & Medicaid Services (CMS) made multiple announcements that could impact where orthopedic care is delivered.

For 2021, CMS added total hip replacement to the list of procedures covered by ASCs—a decision that precedes total knee replacement. Additionally, the agency said it would eliminate the Inpatient Only (IPO) List over three years, starting with 266 musculoskeletal procedures in 2021. The latter decision affects procedures across orthopedics – joint replacement, spine, trauma – allowing them to be eligible to be paid by Medicare in the hospital outpatient setting or hospital inpatient setting, whichever is determined the most appropriate by the physician.

CMS noted that these decisions reduce provider burden so that hospitals and ASCs can operate with increased flexibility, and they provide physicians and patients greater decision-making power.

The American Association of Orthopaedic Surgeons (AAOS) called the elimination of the IPO List “drastic” when CMS released the initial proposal. AAOS noted safety concerns, increased out-of-pocket costs and potential access to care issues for patients, and said the appropriate care settings should be determined through the lens of patient safety and peer-reviewed evidence.

Private payors have covered orthopedic procedures in outpatient settings and even incentivized surgeons for doing so. Recent estimates we published from Sg2 showed total hip and knee procedures and spinal fusion procedures increasing in the outpatient hospital and ASC settings by 31% from 2019 to 2029. At the same time, total hip and knee procedures will decrease in the hospital inpatient setting by -11% and spinal fusions will reduce by -17%.

Orthopedic device companies ultimately see the shift to outpatient procedures as an opportunity. Joint replacement and spine companies are bolstering programs and technologies to capitalize on the change.