This patient has moderate risk of post-operative complications that should be optimized in preoperative setting and followed for post-operative complications and the stay may cross 2 midnights.

The Medicare policy regarding the “two-midnight” rule is unchanged for TKA/THA patients. Providers must assure that documentation in the medical record supports medical necessity. When an inpatient is discharged before two midnights, the expected need for an inpatient stay (i.e., defined as a need for two-midnights) and unexpected early recovery resulting in the discharge must be thoroughly documented by the physician/treating provider, to be billed as an inpatient admission.

Factors which can be considered for 2 MN purpose in TKA/THA:
Inadequate pain control
Drain management
Urinary retention / Ileus
Acute functional immobility
Physical therapy / Rehab needs
Social circumstances / Family support

If an outpatient surgery is converted to inpatient admission, providers must assure that comprehensive documentation in the medical record supports medical necessity.
If an inpatient TKA/THA patient is getting discharged before 2 midnights, an appropriate decision based on clinical judgment is required whether to follow condition code 44 process (inpatient admission changed to outpatient) or to support inpatient admission status with early recovery documentation by treatment team.

We recommend that you consult your Physician Advisor to evaluate the documentation to support medical necessity of each hospital day.

If you prefer an external review by Aerolib`s Physician Advisor team, please email us with your request at