Why documentation matters more than ever: Dr. Joseph Bosco III on CMS, payer policy

Payer Issues

Documentation will be more important than ever if CMS doesn't adjust its 2022 proposal to restore the inpatient-only list, according to Joseph Bosco III, MD, of NYU Langone in New York City.

Dr. Bosco, vice chair of clinical affairs for NYU Langone Orthopedics and outgoing president of the American Academy of Orthopedic Surgeons, spoke with Becker's Spine Review to share his advice for surgeons and discuss the payer landscape as more orthopedic surgeries shift to the outpatient setting.

Note: This conversation was edited for length and clarity.

Question: What efforts have AAOS surgeons made voicing their thoughts about the 2022 CMS proposal?

Dr. Joseph Bosco III: I think what's garnered the most attention is the inpatient-only list and the restoration of it. The academy's position is always that the final decision about the surgical venue and whether it's inpatient or outpatient should be made by the physician in consultation with their patient. You don't need the government or any other entity stepping in and saying, "Oh, this has to be done as an outpatient and this has to be done as an inpatient."

In a perfect world we wouldn't need that because the physician would make the decision with the patient. However, what we see now is once these procedures were taken off the inpatient only list, a lot of payers now default to, "Oh, they have to be done as outpatient surgeries."

We've had some of our members who have had real difficulty trying to get prior authorizations for site of surgery. Basically, they have to get on the phone and talk to the insurance companies about being able to get a patient overnight after a knee or hip replacement.

Q: What one change should CMS make to benefit orthopedic care?

JB: I think that CMS should continue to have the inpatient-only list to protect the physicians and patients against certain types of procedures against certain procedures being mandated.

But, we also think that it would be nice to see CMS give us a little bit of clarity about what criteria these are for inpatient or outpatient procedures. Most hospitals and providers are a little bit leery that at some point you can have these RAC audits that they'll come and say, "Well, how come this patient was done as an inpatient and not outpatient?" So we'd like to at least suspend the RAC audits, which they said they would do for a while.

Q: If CMS' 2022 proposal goes into effect with no changes, what advice will be given to surgeons?

JB: Documentation, documentation, documentation. You could have to document on a chart why you thought the patient had to be inpatient or why you thought that they needed to stay an extra day, and we hope that they would take socioeconomic factors into account.

The typical patient we see in New York and I'm sure in other places are a 70 year old male or female, and they've got some hypertension and hypercholesterolemia, which are not horrible and are under control. So by all intents and purposes, they should be able to go home. But they live in a four-story walk-up and their children aren't around or they work at minimum wage hourly jobs. So they're either not available or they cannot take the time off because they can't afford it. Well, how's that patient going to go home the same day? At this point, the insurance companies aren't taking this into consideration.

Q: How will hospitals and health systems compete with ASCs and these changing insurer policies as more ortho surgeries migrate away from inpatient settings?

JB: We think the migration to outpatient surgery has been accelerating. It's a trend that's been accelerated by COVID-19 that's continuing to accelerate, and the genie's not going to go back in the bottle because people actually do pretty well as outpatients. Now they're motivated because no one wants to stay in the hospital. But as orthopedic surgeons, we are site neutral to that. We just want to do what's right for the patients. So we're finding that as we refine our techniques and we'll get better at it, that we can do more patients as outpatients.

Q: In New York specifically, how do you see the Blue Cross Blue Shield coverage policy to push more surgeries to ASCs affecting the payer landscape?

JB: Obviously when insurance companies or payers try to urge patients to go to outpatient venues it's because it's less expensive. There's true value.

But for physicians, we're just doing what's right for patients. We think that there is a value add to doing knee replacements and joint replacements at ASCs as well as inpatient. It's also safe for the patient. So we're fine with that.

Big hospital systems are starting to get a little concerned because it's really shifting our payer mix. Because now these hospital systems are taking care of a higher percentage of older, sicker patients, which are more expensive and the younger, healthier patients which are less expensive to take care of go to the ASC. So that's the issue for hospital systems, but hospital systems are a very strong lobby. I'm not worried about the hospitals.

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