Will CMS Slash Payments with 10 and 90-day Global Periods?

Are procedure payments in jeopardy?

While most of the attention to the 2019 Physician Fee Schedule proposed rule is focusing on the evaluation and management (E&M) changes, there are other issues which seem to be receiving much less attention than they deserve. And one of those may hit physicians’ wallets who perform procedures.

While we are all familiar with the quality initiatives brought about by 2015 Medicare Access and CHIP Reauthorization Act (MACRA), section 523 of the Act required the Centers for Medicare and Medicaid Services (CMS) to “develop and implement a process to gather and analyze the necessary data on pre- and post-operative visits and other services furnished during global surgical periods other than the surgical procedure itself.” Of course when Congress asks CMS to collect data, it also expects CMS to act upon that data, and in most cases that means they want CMS to cut fees.

What is a global period? With each procedure billable to Medicare, a global period of 0, 10, or 90 days is assigned to cover the global surgery package. CMS describes it as such, “The global surgical package, also called global surgery, includes all the necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes the pre-operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.”

The physician fee schedule, which is published each year, specifies the global period for each procedure and the Physician Fee Schedule Final Rule Physician Time schedule (the 2018 schedule here) actually specifies the type and duration of each visit included in that global period. In practical terms, if a patient is sent to a gastroenterologist for rectal bleeding and a colonoscopy is performed, the global period is 0 days. That means the physician can bill for the service and any follow up visits needed after the procedure.

If the patient is sent to a surgeon for an abscess and an incision and drainage is performed, the global period is 10 days. That includes 8 minutes of pre-evaluation time, 3 minutes of positioning time, 5 minutes of pre-procedure scrub time, 15 minutes for the procedure itself, 10 minutes of immediate post-procedure time, and one level 99212 office visit.

If the patient has gallstones and a laparoscopic cholecystectomy is performed, the global period is 90 days. That includes 40 minutes of pre-evaluation time, 10 minutes of positioning time, 15 minutes of pre-procedure scrub time, 80 minutes for the procedure itself, 25 minutes of immediate post-procedure time, two level 99213 office visits, and one level 99212 office visit.

In 2017, CMS did collect the data requested by Congress and the agency summarized it in the proposed rule. CMS required physicians in a group practice of 10 or more physicians in 10 states to report a no-payment CPT® code with every post-operative visit that was performed during the global period for that surgery during the last six months of the year. And physicians did report the code over 900,000 times. While that seems to be a lot, CMS estimates that only 45 percent of physicians who should have reported the code based on their group size and billed procedures actually reported it.

Reporting varied by specialty with surgical oncology reporting the highest at 92 percent of the time and emergency medicine reporting 4 percent of the time. Orthopedic surgery and general surgery, the two most common surgical specialties, reported 87 percent and 81 percent of the time, respectively. North Dakota had the highest reporting rate of 56 percent; Nevada the lowest at 30 percent.

For surgeries with a 10-day global period, only 4 percent of procedures had a post-operative visit reported. For the highest volume specialties, urology was the highest with 22 percent of procedures having a post-operative visit in the global period and neurology was amongst the lowest with a 1 percent rate.

For a 90-day global period, as expected the percentages were higher, with 67 percent of patients having at least one post-operative visit in the global period. Here, orthopedic surgery led the high-volume specialties with 76 percent of procedures having at least one visit. At the other extreme, only 45percent of interventional cardiologists reported a post-procedure visit within the 90-day global period.

Of course, the first reaction to this data is that since the code had no monetary value, physicians were not reporting it. While this may be true in some circumstances, CMS did do a sub-group analysis of what they termed “robust reporters,” those who consistently reported their post-operative visits. Among that group, CMS reported that 87 percent of procedures with a 90-day global period had a post-operative visit but only 16 percent of procedures with a 10-day global period had a visit. CMS concluded that “these findings suggest that post-operative visits following procedures with 10-day global periods are not typically being furnished rather than not being reported.”

CMS goes on to describe their plans for more data collection “in the near future” looking at “the level of post-operative visits including the time, staff, and activities involved in furnishing post-operative visits and non-face-to-face services.”

What does this mean for physicians who perform procedures? Although one can never predict the actions of CMS, you would have to expect that they are not going to continue to pay for post-operative care if that care is rarely furnished.

Physicians who perform procedures would be wise to watch for announcements from CMS on their future data collection efforts.

Those physicians who are not surveyed will be counting on those who are selected to accurately report so that CMS can actually measure the time and effort expended to care for patients.

If that doesn’t happen, you can be sure CMS is going to start making drastic cuts to payment rates.

If you have ideas on how CMS should evaluate this issue, you can comment until Sept. 10 at: https://www.regulations.gov/document?D=CMS-2018-0076-0001


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Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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