CMS will begin collecting and analyzing postoperative visit data from physicians and non-physician practitioners who furnish specified procedures to Medicare beneficiaries on or after July 1, 2017. This impacts providers in nine (9) states who practice in groups of ten or more practitioners. The following states will be affected: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon and Rhode Island. While postoperative visits furnished during the global period are not compensable, these providers will be required to report follow-up face-to-face encounters using CPT code:
99024 - Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.
Below, we provide further information related to the new requirement.
I. Who Must Report
Post-procedural reporting will affect not only general surgeons, but practitioners across multiple specialties, including primary and urgent care providers rendering minor procedures. Medicare will require practitioners to report postoperative visits furnished to beneficiaries for certain procedures with a 10 or 90 day global period.
Teaching physicians will also be subject to the claim-based reporting requirements the same way that other physicians are. Postoperative visits within the global period should be reported with CPT 99024 along with corresponding modifiers GC or GE to denote the service was performed at least, in part, by a resident.
Practitioners practicing exclusively in groups with fewer than ten practitioners in the nine (9) states, while exempt, are encouraged to voluntarily report as are practitioners outside of the nine mandated states.
II. Procedures Impacted
The 2017 Medicare Physician Fee Schedule (MPFS) Final Rule requires postoperative visit reporting associated with procedures having either a 10 or 90-day global surgical package, that are billed annually by more than one hundred (100) practitioners and are also reported more than ten thousand (10,000) times, or have allowed charges exceeding ten million ($10 million). Using claims data from 2014, CMS derived the list of two hundred ninety-three (293) procedures that require postoperative visit reporting during the global period effective July 1. Click here to access the list.
III. Background
Questionable valuation of a physician’s work as it relates to bundled payment for surgical procedures paved the way for CMS to disassemble global surgical packages in the 2015 MPFS, proposing to pay separately for all postoperative visits normally included in a 10 and 90-day global surgery package. Ultimately prohibited under the Medicare Access and Chip Reauthorization Act of 2015(MACRA); MACRA did, however, require CMS to collect data to value surgical services from a “representative sample” beginning in 2017 to specifically include the number of visits furnished within the global period. MACRA also authorized a five percent (5%) payment withholding from surgical procedures until postoperative visits were reported on claims by selected providers. Payment withholding was not finalized in the 2017 MPFS; however, providers billing these specified procedures will receive one hundred percent (100%) as allowed under the MPFS.
Reports released by the Office of Inspector General had called into question valuation of global surgical payments. The global surgical package, either 0, 10, or 90 days, as defined by the American Medical Association CPT Coding, includes the pre-operative, intra-operative, and postoperative surgical services included in valuation of a given surgical CPT code. In one study, the OIG cites that of three hundred (300) cardiovascular surgical services performed, fewer postoperative services were furnished than included in the payment calculation for the underlying procedure in one hundred thirty-two (132) of the cases reviewed; in seventy (70) instances more postoperative services were delivered relative to valuation of the original procedure. Similar results were demonstrated in orthopedics and ophthalmology reports.
Undoubtedly measuring the value of any service should be based as closely as possible on actual resources utilized to execute the service. Collecting data related to the number and types of visits, as well as other resources utilized to furnish services, aids in proper valuation particularly involving services with a 10 or 90 day global period, where insufficient information was available relative to postoperative care. To foster collection of detailed information related to postoperative visits, a single, all-encompassing code (CPT 99024) was selected, thereby, reducing complexities and potential barriers to reporting.
Reflecting any possible variances in healthcare delivery patterns geographically, nine (9) states of various sizes ranked per number of beneficiaries in different regions of the country, were ultimately selected for claims-based reporting of postoperative visits.
As face-to-face visits do not represent all the work associated with postoperative services, such as collaborating care with other practitioners and reviewing test results, CMS has been authorized to conduct surveys to supplement claims data. Survey data will help secure specific details surrounding other activities integral to postoperative care, information which is not practical to garner from claims.
The compulsory claims-based reporting stands to have a significant impact across health systems as modifications may be necessary to both Electronic Health Record (EHR) and billing platforms. Additionally, the valuation of global surgical services by CMS is sure to be addressed in future rulemaking upon collection and analysis of data.
SunStone offers services specifically geared to assisting hospital based and independent multi-specialty physician groups manage the ever-changing professional regulatory environment. If you have any questions about the 2017 Physician Coding and Policy Updates, please contact Vonda Moon, Principal at vondamoon@sunstoneconsulting.com or Joli Fitzgibbons, Senior Manager at jolifitzgibbons@sunstoneconsulting.com.