Are Medicare Procedure Payments in Jeopardy?

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Original story posted on: September 12, 2018

Is CMS preparing to slash payments for procedures with 10- and 90-day global periods?

While thousands of doctors have submitted mostly unfavorable comments to the Centers for Medicare & Medicaid Services (CMS) on the proposed evaluation and management (E&M) changes, there are other issues that seem to be receiving much less attention than they deserve. And one of those issues may hit physicians who perform procedures in the wallet.

This story beings in 2014, when CMS proposed to eliminate the global surgery period. The agency felt that its method of paying for 10 or 90 days of care in one payment to the surgeon was no longer accurate, so they proposed to eliminate it and pay for post-operative visits on a separate basis. But lobbying by physicians led Congress to demand CMS to stop.

Instead, in 2015, Congress asked CMS to justify its actions and analyze the global period data to ensure that procedure weighting accurately reflected the actual work done by physicians. 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.

Most physicians have a general idea of the global period for most procedures they perform, but few know of its origins. The yearly physician fee schedule specifies the global period (0, 10, or 90 days) for every procedure, and the Physician Fee Schedule Final Rule Physician Time schedule specifies the type and duration of each visit included in that global period.

For example, if a patient is sent to a surgeon for an abscess and an incision and drainage is performed, the global period is 10 days. That includes eight minutes of pre-evaluation time, three minutes of positioning time, five 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.

If we look at one of the most common surgeries performed on Medicare beneficiaries, we see that in 2016, there were over a million cataract extractions. The payment for each of those surgeries includes the surgery day services and four office visits after the surgery. If the average patient is actually only seen three times, that may mean that CMS was paying for close to a million office visits that were not occurring. That’s a lot of visits and a lot of money.

In 2017, CMS did collect the data requested by Congress, and they summarized it in the 2019 proposed physician fee schedule rule. They required physicians in any 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 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 of the code by specialty varied greatly, from 4 percent for emergency medicine physicians to 92 percent for surgical oncologists.

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; neurology was among the lowest, with a 1 percent rate.

For a 90-day global period, the percentages were higher, with 67 percent of patients having at least one post-operative visit. Here, orthopedic surgery led the high-volume specialties, with 76 percent of procedures having at least one visit. At the other extreme, only 45 percent 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 performed a sub-group analysis of what they termed “robust reporters” 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 went on to describe its 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, so expect the relative value units (RVUs) assigned to many procedures to drop.

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. And I suspect that surgeons will not take kindly to that.

The opinions expressed in this article represent the personal views of the author and do not represent the views or recommendations of R1 RCM, Inc.

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Ronald Hirsch, MD, FACP, CHCQM

Ronald Hirsch, MD, FACP, CHCQM 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, 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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