Are Medicare procedure payments in jeopardy?

While hundreds of doctors have submitted (mostly unfavorable) comments to CMS on the proposed evaluation and management changes, there are other issues which seem to be receiving much less attention than they deserve. And one of those may hit physicians who perform procedures in the wallet.

In 2015, Congress asked CMS to analyze the global period data to ensure 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 are aware of the global period and 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 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 ten 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 collected the data requested by Congress, and they summarized it in the 2019 proposed physician fee schedule rule. They required physicians in a group practice of 10 or more physicians in 10 states to report a no-payment CPT code with every postoperative visit that was performed during the global period for that surgery during the last six months of the year. And physicians reported 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 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 postoperative visit reported. For the highest volume specialties, urology was the highest with 22 percent of procedures having a postoperative visit in the global period and neurology was amongst the lowest with a 1 percent rate.

For the 90-day global period, 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 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 did 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 postoperative visit but only 16 percent of procedures with a 10-day global period had a visit. CMS concluded, “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 so expect the 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 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.

Physicians can submit their comments until September 10th.

Ronald Hirsch is vice-president, Physician Advisory Services, R1 RCM, Inc. and can be reached on Twitter @signaturedoc. 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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