Phil Castle, The Business Times

An orthopedic surgeon in Grand Junction has joined in efforts to clear up what he calls regulatory confusion over knee replacement procedures.

The issue is a significant one given the growing number of patients undergoing the procedures, said Dr. Louis Stryker, a surgeon with Western Orthopedics and Sports Medicine at Community Hospital.

Stryker was among 30 representatives from the American Association of Hip and Knee Surgeons to participate in a trip to Washington, D.C., to ask lawmakers and federal officials for their help in providing clarification. “Let us know what the rules are,” Stryker said.

The Centers for Medicare & Medicaid Services (CMS), the federal agency that administers the Medicare program, recently removed total knee replacement from a list of inpatient-only procedures for Medicare beneficiaries, Stryker said.

The change enables physicians to decide whether to perform the procedure on an inpatient or outpatient basis depending on the individual circumstances of a patient.

Under the so-called “two-midnight rule,” the CMS deems short-term hospital stays as inpatient admissions if they span two midnights even though they otherwise should have been billed as an outpatient observation visit.

Although CMS rules apply to Medicare patients, they have what Stryker called “downstream effects” on private insurers that use the rules as guidelines for determining payments, Stryker said.

While some patients undergo total knee replacements and soon go home, other patients require a longer stays if medical conditions warrant or there’s insufficient support at home, he said.

The two-midnight rule and lack of clear admission documentation expectations have prompted some hospitals to instruct physicians to perform all total knee replacements for Medicare patients on an outpatient basis.

The issue is important, Stryker said, because of the growing number of patients undergoing knee replacement surgeries.

By one estimate, 600,000 of the procedures were performed in the United States in 2018. That number is expected to double by 2030.

Given advancing technology and techniques, hip replacement surgeries on an outpatient basis are coming as well, he said.

A specialist in knee and hip replacement surgeries, Stryker estimated  60 percent to 70 percent of his practice involves those procedures.

Stryker said he expects CMS to offer clarification, but it could take time. “It’s a slow process.”

In the meantime, Stryker said he’ll remain focused on caring for his patients while accommodating the rules. “You do the best you can. You make an honest effort.”