Considering Inpatient Status For Medicare Total Knee and Hip Patients

By Juliet Ugarte Hopkins, MD, ACPA-C

The Centers for Medicare and Medicaid Services (CMS) have provided guidance on when patients undergoing total hip and total knee arthroplasty—typically outpatient procedures—may qualify for Inpatient status. In this article we explore these scenarios and the documentation requirements which would support Inpatient status. Key factors include the presence of significant co-morbidities, anticipation of a complex procedure related to the patient’s anatomy, patient history of anesthesia complications, or the surgeon’s anticipation that the patient will require Skilled Nursing Facility (SNF) placement post-procedure. This insight can also be used as a utilization management screening tool to assist with pre-operative clinical reviews to ensure appropriate authorization and level of care is made.

Potential Considerations to Hospitalize as Inpatient

If any of these conditions are present, the increased risk associated with the procedure and higher potential of post-operative complications will likely support Inpatient, even if there is not a two-midnight anticipation.  Other patient-specific medical conditions with a two-midnight anticipation of need for hospitalization before the patient is safe to discharge would also be appropriate for Inpatient status, per the Medicare Two-Midnight Rule.  However, patients who are anticipated to discharge on the day of the procedure are not appropriate for Inpatient and should remain Outpatient.

1. Surgical expectation patient will require transfer to a SNF post-procedure for skilled care

• Issue: Situations CMS has provided in the past include no family or friends to assist the patient at home, multiple stairs in the residence, or other unmanageable obstacles in the home environment. 

• Documentation Tip: Detail the reasons why the patient will need skilled care in a facility and will not be appropriate for discharge to home post-procedure. 

2. Body Mass Index (BMI) ≥ 40:

• Issue: Elevated BMI can lead to increased surgical and anesthesia risks, necessitating closer post-operative monitoring.

• Documentation Tip: Provide the current BMI contributing to heightened risk and detail the monitoring provided.

3. Poorly Controlled Diabetes Mellitus (HbA1C > 7.5%):

• Issue: Heightened risks of post-operative hyperglycemia and wound infection.

• Documentation Tip: Include the date and result of the patient’s most recent HbA1C and the associated surgical risks.  Include the plan for a specific cadence of blood glucose and wound monitoring.

4. Chronic Anemia (Hemoglobin < 11):

• Issue: Baseline anemia necessitates careful monitoring for blood loss and post-operative monitoring for signs and symptoms of escalated anemia possibly requiring transfusion.

• Documentation Tip: Specify the patient’s last hemoglobin level before the procedure and the plan for monitoring for escalated anemia post-operatively.  Document hemoglobin levels following the procedure and any signs/symptoms possibly related to worsening anemia.

5. Chronic Kidney Disease Stage 4 or 5 (CKD IV/V):

• Issue: Presence of advanced CKD requires close monitoring for anesthesia-related risks, fluid balance issues, and potential development of acute kidney injury.

• Documentation Tip: Highlight the pre- and post-procedure creatinine levels.  Detail plans for escalated fluid delivery or potential need for nephrology consultation.

6. Coronary Artery Disease (CAD) requiring chronic medication management:

• Issue: Increased surgical risks requiring close post-operative monitoring.

• Documentation Tip: List the routine medications the patient takes for CAD and the potential for increased surgical complications related to this condition.  Detail the plan for close monitoring for cardiac decompensation.

7. Uncontrolled Hypertension despite chronic medication management (BP > 140/90):

• Issue: Increased surgical and bleeding risks.

• Documentation Tip: Include the patient’s blood pressure readings pre-operatively in the clinic setting and the plan for close monitoring post-operatively.

8. Chronic Obstructive Pulmonary Disease (COPD) on routinely administered oral or inhaled medications:

• Issue: Increased risk of perioperative respiratory failure and other complications.

• Documentation Tip: List the routine medications the patient takes for COPD and the potential for development of respiratory compromise related to this condition.  Detail the plan for close monitoring for pulmonary decompensation.

9. Baseline Abnormal Mental Status:

• Issue: Patients with pre-existing cognitive issues often develop escalated decompensation in mental status following administration of anesthesia and in relation to many medications given for pain control post-operatively.

• Documentation Tip: Describe the patient’s baseline mental status and the monitoring protocols planned while the post-operative pain management regimen is established and tailored to the patient’s needs.

Key Takeaways

• Initial Documentation is Crucial: Justification of Inpatient hospitalization requires documentation in the History and Physical or post-operative note which thoroughly explains why the patient’s condition warrants closer monitoring or additional care.

• Length of Stay: While a two-midnight stay is not always necessary, the rationale must clearly establish why there is increased risk or complexity associated with the patient’s condition.  Even in cases where there is documented risk, patients who are anticipated to discharge on the day of the procedure should remain Outpatient.

• Daily Documentation Especially for Patients Requiring SNF Transfer: Daily records must reflect the patient’s ongoing need for hospital services and what hospital services are being provided.  “Waiting for transfer to SNF” is not acceptable.