Surgeon Payments in the Crosshairs Following HHS OIG Audit

Today, in utilization news, there is a warning to any surgeons who may be reading this – or anyone who works with surgeons. You may see new efforts by the Centers for Medicare & Medicaid Services (CMS) to lower your fees in coming years. We have all heard about the fact that the Physician Fee Schedule has not kept up with inflation, and how angry physicians are about it, but there is a new threat on the horizon.

As background, surgeries have what is called a “global period.” The payment for the surgery to the surgeon covers that global period, which starts on the day of surgery and ends either that same day (as with a colonoscopy or simple laceration repair), after 10 days (as with an hemorrhoidectomy), or after 90 days (for major surgery). You can look up the global period for any CPT code here: https://www.cms.gov/medicare/physician-fee-schedule/search.

For each global period, CMS uses data from surgeons to determine the average time spent on each task on the day of surgery, including visiting the patient in pre-op, positioning the patient, scrubbing for surgery, performing the surgery, and then time spent post-operatively that day (and then the number of times that the patient is seen in the hospital, office, or other setting starting the day after surgery). And from that, they set the payment rate.

For example, we love to talk about total knee arthroplasty. So let’s take CPT code 27447 as an example. It has a 90-day global period. CMS estimated that 187 minutes are spent by the surgeon on the day of surgery, then they have three post-operative hospital visits and three post-operative office visits. Looking at a lesser surgery, incision and drainage of a simple abscess has a global period of 10 days, 41 minutes on the day of the procedure, then one follow-up office visit.

So, why are payments at risk? Well, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) did an audit, pulling medical records on 105 surgeries, and looked for the number of visits that occurred after the day of surgery. And not surprisingly, the number of visits was fewer than the number that CMS used to set payment rates. Now, of course, just looking at the CMS numbers for total knee replacement, any of us could have told the OIG that most patients do not stay in the hospital for three days after surgery, but that aside, with this audit there will be increased pressure on CMS to revisit the way they determine how many visits a surgeon has with their patients – and that may lead to reducing the payment for many surgeries. And that would not go over well.

If surgeons want to act now, they need to ensure they are reporting their post-op visits during the global period to CMS by using CPT 99024, which is not paid, but tells CMS they are in fact seeing their patients in the office.

One more update: as of July 1, there is a requirement in the discharge planning Conditions of Participation at 42 CFR 482.43(c) to have formal transfer protocols and perform annual training. Note that this applies only to inpatients and not ED patients, for whom the Emergency Medical Treatment and Active Labor Act (EMTALA) likely applies, or outpatients at any location in the hospital, but it does apply to transfers (both to other hospitals and also within the hospital to a different unit). Why did CMS add this requirement? They state “that effective transfer processes can improve transitions of care, increase a hospital’s ability to transfer patients promptly to facilities able to appropriately care for them, as well as protect the health and safety of all patients, including pregnant, birthing, and postpartum women.”

I suspect that many hospitals already have such policies in place, but you should ask your hospital’s survey organization liaison to confirm that such policies exist – and if you have required formal training for applicable staff.

With a requirement becoming effective mid-year, the survey organizations may be eager to catch hospitals that miss the deadline.