Federal Regulatory Wins

The AAOS Office of Government Relations’ regulatory efforts ensure that orthopaedic concerns are addressed even after the conclusion of the legislative process and throughout agency rulemaking and implementation stages. To this end, the regulatory staff works closely with Department of Health and Human Services agencies such as the Food and Drug Administration (FDA), Centers for Medicare & Medicaid Services (CMS), the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Disease Control and Prevention (CDC). In addition, expertise in coding, reimbursement, and payment policy is shared across the Academy and with our members. The Office of Government Relations also houses the AAOS’ patient safety, quality, registry and research advocacy efforts. All of these are key services to our fellowship and members.

CMS Guidance on TKA out of the Medicare IPO list

On January 8, 2019, in a major win for AAOS’ advocacy efforts, the Centers for Medicare & Medicaid Services (CMS) issued an unprecedented guidance to help resolve confusion surrounding the removal of  total knee arthroplasty (TKA) from the Medicare Inpatient-Only only (IPO) list. The policy change, which was made in the 2018 Medicare Outpatient Prospective Payment System (OPPS) Final Rule,  allows for payment of the procedure in either the hospital inpatient or outpatient setting. This guidance reiterates that the surgeon is the final arbiter of the setting of care and provides several clinical case studies to guide how CMS’ Quality Improvement Organizations (QIOs) will review claims based on the two-midnight rule. The guidance can be found here

Scoliosis Screening

On January 9, 2018, the United States Patient Safety Task Force (USPSTF) released updated guidance on screening for adolescent idiopathic scoliosis. The guidance was upgraded from “D”, discouraging screening, to “I”, indicating the data is inconclusive on the effectiveness of screening. POSNA and SRS led a letter in June 2017 signed by 13 other BOS societies as well as AAOS and the American Academy of Pediatrics urging the USPSTF to upgrade their recommendation. Read the USPSTF’s announcement here

Medicare Access and CHIP Reauthorization Act (MACRA) and the Quality Payment Program

AAOS submitted comments to CMS on its proposed rule that would make changes in the third year of the Quality Payment Program, including participation requirements for 2019. The 2019 Quality Payment Program proposed and final rules took significant steps to respond to AAOS’ concerns for needed flexibility and simplification, as well as protection for small, solo, and rural practices.

In the Final Rule, CMS specifically addressed our request that it not eliminate or reduce the Small Practice Bonus as proposed. AAOS requested that if CMS assigned the Bonus to the Quality performance category, it should not reduce its value from 5 points. CMS acknowledged our request and, in fact, raised the Bonus from 5 to 6 points. AAOS is working to introduce an incentive-based third pathway/alternative to the MIPS and Advanced APM tracks that reduce clinician burden while improving payment incentives.

Read the entire AAOS comment letter here

Evaluation and Management (E/M) Documentation Changes

In response to AAOS comments regarding proposed revisions to Evaluation and Management (E/M) Services as part of the Medicare Physician Fee Schedule  Rule 2019; CMS implemented changes to documentation policies to reduce clinician burden. CMS will preserve the current coding for complex patients, delaying collapse of E/M codes 99201-99215 to the year 2021. AAOS continues to be involved in discussions regarding proposed changes to the to the coding and payment system through the AMA’s CPT/RUC Workgroup on E/M and is participating in new code valuation processes.

Site Neutral Payment Policies in Medicare Outpatient Final Rule 2019

The final rule included expansion of site-neutral payments that would remove incentives for hospitals to employ private practices and would level the playing field. It also has proposals for physician office equivalent payment rate for clinic visits at an off-campus provider-based department (PBD) which would lower out-of-pocket for patients. The rule also updates the ASC payment using the hospital market basket and separates payment for non-opioid pain management in ASCs.

Bundled Payment Models

On January 9, 2018, CMS announced a new voluntary bundled payment model that will qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program. This new model, called “Bundled Payments for Care Improvement Advanced” (BPCI Advanced), which launched on October 1, 2018, requires participants to bear financial risk, have payments under the model tied to quality performance, and use Certified Electronic Health Record Technology. The pricing methodology of this new model no longer relies on the National Trend Factor (NTF), as AAOS has consistently argued that the NTF is detrimental to the sustainability of BPCI models.

AAOS has some additional concerns including the model’s interaction with CJR, the semi-annual reconciliations, and benchmark price consideration. Recently, however, CMS notified convenors of an anticipated Amendment to the participation agreement which we expect will eliminate the 50 percent cap on physician reimbursement. The anticipated change is a huge win for our legislative and regulatory advocacy as AAOS continues working to ensure that interested orthopaedic surgeons have the tools and resources needed to participate. This includes a well-attended webinar, which aired on February 21, 2018, and several formal communications with CMS.

For the webinar and to read more about these issues, visit: www.aaos.org/advocacy/medicarepaymentcms/

Surgical Risk Reduction Toolkit

AAOS continually works to develop ways to help fellows and active members improve the quality of their practice, decrease complications, and increase the value of their work to society. The SRR Toolkit is designed to help identify patient-specific risk factors that can be medically optimized throughout the care episode and provide resources to help the doctor-patient partnership manage and optimize specific risks for each patient. The easiest pathway to improved patient outcomes following complex orthopaedic surgery is avoiding medical complications that lead to increased length of stay, hospital readmission, and return to the operating room. The methodology takes advantage of easily accessible resources to create a team approach to address known avoidable complications and improve clinical outcomes. The toolkit is housed on AAOS.org.

Family of Registries

Working closely with CMS, AAOS was accepted into the Research Data Assistance Center (ResDAC) program and on April 13, 2013, CMS announced at AAOS would be granted access to Medicare claims data for registry needs.

The 2019 Physician Fee Schedule/Quality Payment Program (PFS/QPP) proposed rule recommended requiring a QCDR measure owner “to agree to enter into a license agreement with CMS, permitting any approved QCDR to submit data on the QCDR measure”. This had significant negative implications for AAOS registries. The proposal would have infringed on a QCDRs intellectual property rights, impacted the ability to recoup costs related to the significant capital, resources, staff, and time that is needed to approve performance measures, and stifle innovation by rewarding those who aren’t creating measures and penalizing those who are. AAOS wrote detailed comments opposing this provision and singed onto a letter by the Physician Clinical Registry Coalition (PCRC) that also expressed this sentiment. A phone call was held with CMS to discuss this issue, among others. When CMS released their final rule on November 1, 2018 they stated that “based on the feedback and concerns raised by stakeholders, in the interim, we are not finalizing this proposal” – this was a big win for registries.