This sample policy for total knee replacement admission decisions was developed by Ronald Hirsch, M.D., vice president of regulations and education at R1 Physician Advisory Services. Contact him at rhirsch@r1rcm.com.

I. SCOPE

This policy applies to patients at St. Elsewhere Health System with traditional health insurance provided by Medicare, also known as fee-for-service Medicare, and not enrolled in a Medicare Advantage plan, who are undergoing an elective total knee replacement (TKR).

II. PURPOSE

The purpose of this policy is to provide guidance to clinical staff and other personnel on the proper procedures and requirements for all patients to receive services for the appropriate patient status based on regulations issued by the Centers for Medicare & Medicaid Services (CMS). Per CMS, the clinical staff are most suited to create such guidelines (82 FR 59383).

III. POLICY

The patient status of every patient undergoing TKR will be determined prior to surgery by the performing surgeon after review of this policy. The patient status must be recorded in writing prior to the date of surgery, with the order dated and signed by the surgeon, or another physician or practitioner who will be involved in the care of the patient and has admitting privileges at the hospital. If inpatient admission is ordered, the inpatient admission formally begins when the patient enters the operating suite. If the surgery is cancelled prior to the patient entering the operating suite, the inpatient admission will have not started, and any services provided to the patient in the preoperative preparation area may be billed as outpatient services.