The Centers for Medicare & Medicaid Services (CMS) created and implemented the hospital Outpatient Prospective Payment System (OPPS) in 2001, as required by the Social Security Act. The OPPS required that CMS identify those services that could safely be provided to Medicare patients in the outpatient setting of a hospital, initially considered a stay of less than 24 hours. For services and procedures that were identified as inpatient only, CMS created an “inpatient-only list” that is updated annually in the OPPS final rule, published November 1 each year. This article provides an update to a previous Bulletin column, “What surgeons should know about…The inpatient list,” published in June 2013.*
What is the Medicare inpatient-only list?
The Medicare inpatient-only list refers to procedures and services that CMS has identified as typically only provided in the inpatient setting and therefore not paid under OPPS. Many of the services on the inpatient-only list are surgical procedures that may be complex, complicated, and/or require the care and coordinated services provided in the inpatient setting of a hospital. It is important that surgeons be aware of procedures that are on this list because of the potential impact on reimbursement and interactions with their hospital.
Does the Medicare inpatient-only list change?
Each year, clinicians, specialty societies, and other stakeholders contact CMS to request that procedures identified by American Medical Association Current Procedural Terminology (CPT)† codes be reviewed and considered for addition to or removal from the inpatient-only list. Since the inception of the OPPS, some hospital stays have extended beyond 24 hours and up to 48 hours. In addition, medical technology has improved, coordination of care has improved across different clinical settings, and the effective and successful management of non-Medicare patients in the outpatient setting has led to many services being removed from the inpatient-only list.
When considering whether to add or remove a procedure from the inpatient-only list, CMS considers the type of procedure or service being performed, whether the procedure is safely being performed on non-Medicare patients in the outpatient setting, and whether any published data on outcomes are available to help in the decision-making process.
Will I get paid if I perform a procedure in the outpatient setting if it is on the inpatient-only list?
A physician who performs an inpatient-only list procedure in the outpatient setting of a hospital may receive payment if the documentation for the procedure meets requirements for medical necessity. The hospital, however, will not be paid for the procedure. Consequently, hospitals will often have someone from the quality or case management team review the medical record early in the patient’s stay to assess the appropriateness of the admission and assess whether medical necessity for inpatient care is supported by the documentation in the medical record.
Were there any changes to the inpatient-only list in 2018?
The American College of Surgeons (ACS) reviews the procedures on the inpatient-only list on an annual basis and makes recommendations to CMS regarding those procedures that can be removed from the list without compromising patient safety or quality. The ACS also comments against the proposed removal of procedures from the list. The changes to the inpatient-only list for 2018 are provided in Table 1. For a list of all the CPT codes that are included in the Medicare 2018 inpatient-only list, see Addendum E of the OPPS final rule.
Table 1. 2018 changes to inpatient-only list
|CPT Code||Long descriptor||Inpatient-only list
2018 status change
|27447||Arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing (total knee arthroplasty)||Removed|
|43282||Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh||Removed|
|43772||Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only||Removed|
|43773||Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only||Removed|
|43774||Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components||Removed|
|55866||Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing; includes robotic assistance, when performed||Removed|
|92941||Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel||Added|
*Ollapally V. What surgeons should know about…The inpatient list. Bull Am Coll Surg. 2013;98(6):54-55. Available at: nowherefacs.wpengine.com/2013/06/the-inpatient-list. Accessed March 13, 2018.
†All specific references to CPT codes and descriptions are ©2017 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.