Hike Through the Process of Total Knee Arthroplasty

Get a personal perspective on consumer-driven healthcare, technology, procedures, outcomes, and partnerships.

Many years of weekend athletics, hiking New Hampshire’s White Mountains, and three meniscus repairs left my right knee without cartilage. Standard conservative treatments — including nonsteroidal anti-inflammatory drugs (NSAIDS), hyaluronan injections, steroid injections, and physical therapy (PT) — proved ineffective, over time. I assumed I had to live with the pain and dysfunction because I was too young for a knee replacement. But as a good consumer of healthcare, I researched total knee arthroplasty (TKA) and learned that technology had advanced to the point of having developed custom joints. I spoke with my surgeon, David Thut, MD, about my research of ConforMIS, one of many manufacturers of custom joint prosthetics.

Custom Joint Replacements
Mean Better Options, Outcomes

One complaint about standard knee prosthetics, particularly for women, is that they are often unable to replicate the shape, size, and contours necessary for a comfortable fit. This is where advancing technology plays a role.
Two months prior to my surgery, I was sent for a computed tomography (CT) scan of both knees from mid-shin to thigh. ConforMIS used computer-aided design (CAD) to transform the CT image into a custom knee joint. Based on patient-specific measurements, including any underlying joint deformity, ConforMIS created both a custom prosthetic and, using 3-D printer technology, custom surgical tools to assist the surgeon with the implantation. The custom prosthetic was delivered to the hospital within days of the surgery.
Because this is a new technology, ConforMIS provides a great deal of surgeon support. According to Director of Provider Relations Amy Connors at ConforMIS, all surgeons who opt to perform TKAs using ConforMIS products can receive an intensive onboarding program including real-time training in a cadaver lab, video instruction, and peer-to-peer support. This research made me comfortable about my choice.
Patients also are provided education to help them understand the challenges they’ll encounter as they go through surgery, the post-operative course, and PT. I attended “Joint Camp,” where I met an operating room nurse, members of the recovery team, a physical therapist, an occupational therapist, and members of the integrative medicine group. I was introduced to pre-surgical planning ideas that included information on relaxation techniques and “pre-hab” PT, and listened to a presentation on what I could expect during my hospital stay. I was advised to visit my primary care physician (PCP) for a pre-operative examination. Following the guidelines of patient-centered care and cost-containment, there were no pre-disposing factors present that would warrant other tests. After a comprehensive physical exam, I was cleared for surgery.


More than Ever, Informed Patients Are Driving Healthcare Decisions
As my experience shows, healthcare has become a customer-driven service industry. According to the National Center for Policy Analysis, more and more patients are managing their healthcare through their own research of diseases, treatments, and technologies and seeking options that fit their needs. Rising insurance premiums and deductibles are also enticing patients to seek treatments that will result in the best and most cost-effective outcomes.

Surgery and the Road to Recovery

During TKA surgery, diseased portions of the knee joint are removed, and the remainder of the joint is reshaped to fit the knee prosthetic. A 5- to 10-inch incision (depending on the patient’s body habitus) is made along the front of the knee, which allows access to the joint and permits the surgeon to move the patella away from the surgical area.
Using the custom guides and instruments, the surgeon fits and cuts the distal femur to accommodate the femoral component of the prosthetic. The surgeon removes damaged bones and cartilage from the tibia, and again uses custom guides and instruments to fit the tibial component of the knee prosthetic to the bone. The anterior cruciate ligament (ACL) and the medial and lateral meniscus are removed, as well. Both components are set in place with bone cement, and holes are drilled for pins according to the custom instrumentation to ensure accurate placement.
The patella is brought back into position and adjusted to fit over the prosthetic joint. Frequently, a plastic component is added to return the patella to its normal position. The surgeon bends and flexes the knee to make sure range of motion and patella balance are satisfactory, and may make adjustments prior to cementing the prosthetic components. The incision is closed with subcutaneous stitches and covered with a two-part skin closure system that provides a skin adhesive covered with a self-adhesive mesh for excellent skin approximation and healing, eliminating the use of staples. Anesthesia includes a regional and spinal block, and post-operative pain medication.
My surgery took just over an hour, and recovery was uneventful. TKA patients are expected to get up within 12-18 hours following their surgery. I had to demonstrate to the physical therapist I was able to navigate stairs, get into and out of an automobile, and walk unassisted for several hundred feet before I was able to go home on the second day.
I used a walker the first day post-surgery, but by the second day I was more comfortable using crutches. Pain is managed by opiates, which may be a challenge for patients who have difficulty tolerating the side effects. Ibuprofen, naprosyn, and acetaminophen may also be used, and aspirin is used as a deep venous thrombosis(DVT) prophylaxis. Ice is encouraged, and PT continues at home for as long as the patient is homebound (which, for me, was one week).
I continued PT on an outpatient basis, and was able to walk independently on day four and drive after three weeks. To produce the best post-operative outcomes, physical therapists focus on three goals:

  • Range of motion, including complete straightening of affected leg and eventual bending to at least 120 degrees or more;
  • Quadriceps and hamstring strengthening to support proper body mechanics as patients relearn to walk; and
  • Tissue massage to relieve muscle pain, scar adhesions, and neurological symptoms related to surgical nerve damage.

Each patient is different, and goals are set to ensure that the post-surgical results meet the pre-surgical expectations.

Capturing Reimbursement for TKA

The use of a custom prosthetic does not affect coding. The proper code for the surgery is 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty). Physician reimbursement for this procedure, per the Centers for Medicare & Medicaid Services (CMS), is approximately $1,400 (national average).
Diagnosis related group (DRG) 470 reports a major joint replacement of lower extremity without a major complication or co-morbidity. Reimbursement for northeast hospitals (per 2016 Inpatient Prospective Payment System (IPPS)) is approximately $30,000, based on the typical two-day length of stay with no post-operative complications.
ICD-10-PCS codes are based on root operation, approach, laterality, and whether cement was used. In my case 0SRC0J9 Replacement of right knee joint with synthetic substitute, cemented, open approach is the appropriate code.
Diagnosis coding in ICD-10-CM now reports laterality: M17.11 Unilateral primary osteoarthritis, right knee. Facility claims are submitted with additional diagnostic information: any chronic conditions that might affect surgery or the hospital stay, such as long-term use of certain medications, chronic conditions (as evidenced by current treatment), family history of coagulation defects, and any condition that is present on admission.

Healthcare Payments Are Evolving to Contain Costs

This is not an inexpensive surgery, and there are no guarantees that patients will recover to their best pre-surgical status; however, steps are being taken to both reduce costs and improve outcomes in all areas of patient care.
An innovative CMS initiative called Bundled Payments for Care Improvement (BPCI) is changing the way hospitals look at patient care, from the acute phase to recovery and throughout the global period. Hospital payment, called the Net Payment Reconciliation Amount (NPRA), is calculated based on a particular target price that considers the DRG times the number of episodes of care, with further payment adjustments based on fee-for-service (FFS) payments, readmissions, and other factors. If providing the bundled services with expenses running over this NPRA amount, the hospital will owe CMS. If the hospital comes in under this amount, there is an additional chance for goal sharing, as well as the payment. The point of Bundled Payments for Care Improvement is not payment reform, but to improve care planning with the goal to achieve positive financial results without compromising patient outcomes. Commercial payers have not adopted this program and are reimbursing hospitals on either an FFS or a DRG basis.
Physicians continue to be reimbursed on an FFS model, and share no financial risk in this program. Because a patient’s surgical stay and post-operative results influence the ability for hospitals to take advantage of the bundled payment initiative, they are looking for ways to improve the patient’s pre-operative health status.
Both Wentworth-Douglass Hospital (WDH) in Dover, New Hampshire, and ConforMIS are concerned about patient outcomes, and they have identified that patient education and perception is linked to excellent recovery. Along those lines, Executive Director, Marketing Communications and Public Relations, Beth Best at ConforMIS is developing a Patient Advocacy Program to assist potential and current joint replacement patients by putting them in contact with successful post-surgical individuals. By sharing experiences, Best hopes that patients will be able to make informed decisions to assist their surgical experience and recovery.

Patient Compliance Can Play a Larger Role

Hospitals are increasingly experiencing pre-certification denials from commercial payers who do not want to take on the risk of approving procedures such as joint replacements for co-morbid patients, for which they have historical claims data. In addition to the patient’s physical pre-operative status, the patient’s own concept of their health and recovery may be linked to outcomes, with fear and lack of understanding affecting their recovery. With that in mind, and to meet bundled payment goals, hospitals are looking more closely at patient’s pre-operative status by initiating perioperative risk screening and mitigation programs to ensure the most positive outcome. Vice President of Musculoskeletal Services Steven Wyrsch at WDH recently introduced this program, which is bundled into the entire surgical package and incurs no additional cost to the patient. It focuses primarily on orthopedic patients who are referred by their surgeon, and determines whether patients require pre-operative management to provide surgical risk reduction for more than two-week’s duration.
The program at WDH addresses issues like nutritional counseling, smoking cessation, and pre- and post-surgical rehabilitation. A plan is put into place, with patient involvement and compliance as a key driver of the model. Non-compliant patients are referred back to their PCP for more aggressive disease management, and surgery is postponed until the patient is able to obtain optimal results from the pre-operative plan. Rather than disqualify patients from having major surgical procedures, this program allows patients to take charge of their own healthcare and make improvements to insure an optimal healthcare experience. The hope is that patients will be more prepared for the demands of a major orthopedic surgery, and will have a more realistic and optimistic view of their recovery process.
It’s clear that patients are not the only players in the healthcare game who are concerned about technology, outcomes, and costs. The field of healthcare technology is quickly becoming a strategic player in the goal to improve patient satisfaction by offering their own patient-tailored education and support. For years, hospitals and physicians have been reporting metrics from a patient satisfaction and safety perspective. Improvement continues as they use best-practice approaches and implement new technology and educational strategies to ensure excellent clinical outcomes in this patient-focused trend.
National Center for Policy Analysis: www.ncpa.org

Pam Brooks, MHA, CPC, COC, PCS, is the coding manager at Wentworth-Douglass Hospital in Dover, N.H. She has a Bachelor of Science in Adult Education from Granite State College and holds a Masters in Health Administration from St. Joseph’s College of Maine. Brooks leads a team of multi-specialty professional and facility coders, auditors, and CDI specialists, and is the vice president of the Seacoast-Dover, N.H., local chapter. She served on the AAPC Chapter Association board of directors from 2013-2016.

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Pam Brooks, MHA, CPC, COC, PCS, AAPC Fellow, is manager of regulatory billing audit at MaineHealth. She is responsible for the corporate billing auditing and compliance program, serving nine hospitals and several other healthcare facilities. Previously, she led a team of professional and technical fee coders and auditors for a N.H. community hospital. She is a member of the Portland, Maine local chapter and currently serves on the HEALTHCON Education Committee. She served on the 2015-2018 National Advisory Board and is a frequent contributor to Healthcare Business Monthly. She speaks regionally and nationally on coding, auditing, and career development topics. Brooks holds a bachelor’s degree in adult education and workplace training from Granite State College and a master’s in health administration from St. Joseph’s College of Maine.

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