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2019 Medicare Physician Fee Schedule Rule Includes Potentially Misvalued Codes for THA/TKA

The Centers for Medicare and Medicaid Services (CMS) recently released the 2019 Medicare Physician Fee Schedule Final Rule and identified seven high volume current procedural terminology (CPT) codes as potentially misvalued, amongst which were 27130 (total hip arthroplasty) and 27447 (total knee arthroplasty). CMS requested the RUC (Relative Value Update Committee) of the American Medical Association re-evaluate the work for these procedures.

CPT codes 27130 and 27447 were reviewed by the RUC and CMS in 2013. At their October 2018 meeting, a subcommittee of the RUC evaluated the request for review of these seven codes and did not find reason to reevaluate them. Our own review of relevant materials disclosed by CMS this month persuades us that there is no valid indication that the work, complexity and effort of care physicians provide patients undergoing these procedures have changed since then. In fact, recent physician-led quality initiatives have yielded substantial improvements in the value of these procedures. In many cases, the cost of a 90-day episode of care has been reduced by 50% without any reduction in quality. Therefore, The American Association of Hip and Knee Surgeons (AAHKS) does not believe that these codes should be reviewed by the RUC at this time.

Total hip arthroplasty and total knee arthroplasty have been at the forefront of the value-based care initiatives that CMS and others developed, such as Bundled Payment Care Initiative (BPCI) Classic, BPCI Advanced, and the Comprehensive Care for Joint Replacement programs. The societal value of these procedures is unquestionable, and demand already exceeds supply. Lowering the valuation of these codes will surely add to the supply-side crisis and threaten access for patients. As these programs evolve, there should not be re-evaluation of these codes in the absence of new data to support a change in work. Further, most stakeholders agree that participation in value-based programs actually generate more work than the classic fee-for-service model, and data supporting this claim are forthcoming.

AAHKS President Craig J. Della Valle, MD stated, “Our members have worked very hard over the past decade to improve the quality of care they provide for patients undergoing hip and knee arthroplasty while simultaneously partnering with payors including the Federal government to lower costs. Given the high societal value that these procedures provide, penalizing the surgeon (whose compensation is a small fraction of the total cost of the episode of care in DRGs 469 and 470) for improvements in care seems unfair, misguided, and may threaten access to care.”

Additional resources:

View the CMS final rule
AAHKS summary of final rule
AAHKS comments on proposed rule
AAOS comments on proposed rule

About the American Association of Hip and Knee Surgeons:

Established in 1991, the mission of AAHKS is to advance hip and knee patient care through education, advocacy and research. AAHKS has a membership of over 4,000 surgeons and other hip and knee health care professionals.

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Source: PRWeb
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