Neurosurgery Coding Alert

You can anticipate a potential to eliminate disparities for E/M payments in global periods.

CMS’s proposed rule for the Medicare Physician Fee Schedule (PFS) was released this summer. This proposal has taken coders by surprise. According to this proposal, there is a potential for cutting global periods for surgical procedures. You may think it will make life easier for your practice and at the same time worry that this could also mean less money from surgeries. Gear up to take in any changes that may follow in the next few years to report an office visit for a patient that your neurosurgeon operated upon. 

Review Current Practices

Currently, your physician performs surgical procedures that fall primarily into one of three categories: 0 global days, 10 global days, or 90 global days.

What this means: The global surgical package “includes all necessary services normally furnished by a surgeon before, during, and after a procedure,” according to CMS. That includes pre-op, intra-op, and post-op services by your surgeon or any member of your surgical group.

Here are the current groupings:

0-day: Zero-day global surgeries include procedures like endoscopies and other minor surgeries. For these procedures, there is no pre-operative or post-operative period other than the day of the procedure, but you can’t separately bill an E/M service that is related to the surgery on the day of the procedure.

10-day: A 10-day global period consists of 11 actual days, including the day of the surgery and 10 days following the day of surgery. The pre-operative period the day of surgery is included. Many minor surgical procedures carry a 10-day global period.

90-day: A procedure with a global period of 90 days consists of 92 days — one day before the procedure, the day of surgery, and the 90 days of post-operative care immediately following the surgery. You’ll find that major surgical procedures carry a 90-day global period. 

During these global periods, you shouldn’t separately bill E/M services that are part of the normal pre-op, surgical, or post-op care. That includes any E/M procedure provided during the post-operative period that is related to the recovery from the surgery, including pain management. The proposal to eliminate global periods could change all of that. 

Eliminate 10- and 90-Day Global Periods

You might be surprised to learn what CMS is suggesting. In specific, CMS is proposing to transform all 10- and 90-day global codes to 0-day global codes. “Surgeons may welcome this change, but whether it bodes well or ill for practices really depends on how CMS decides to value the surgical codes once the agency removes the global periods from the value units,” says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

Caution: If CMS goes through with this proposal, the agency will be watching patterns of billing post-op E/M services. “We [want to] ensure that allowing separate payment of E/M visits during post-operative periods does not incentivize otherwise unnecessary office visits during post-operative periods. If we adopt this proposal, we intend to monitor any changes in the utilization of E/M visits following its implementation.”

“The challenge for practices and the surgeons will be in tracking their E/M services as well as the documentation created for the particular level of service requested,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. “Since current global surgical services include postoperative visits that are usually valued between a 99212 and 99214, concerns have been raised in the past regarding whether the level of documentation provided supports the level of services currently being accounted for.”

Mark these implementation dates: The proposal is not firm as yet. CMS will look for data to support the updated values for global codes. Depending upon the availability of these data, CMS currently proposes the transition for current 10-day global codes in 2017 and for the current 90-day global codes in 2018. However, your practice should learn the facts now so that you can look out for your future bottom line. 

Why This Transition?

Experts have been trying to assess how the transitioning of all 10- and 90-day global codes to 0-day global codes could impact practices. Many believe that this transitioning could increase the accuracy of PFS payment. This transition may set payment rates for individual services based more precisely upon the typical resources used in performing the procedures. “The work RVU’s differences between 10-90 global codes are not always clear,” says Lisa Fisher Blackmon, CPC, surgical coder at Integrated MD Solutions, Inc., in Daphne, AL. However there is a difference in opinion too. “The PFS payments could lead to payment disparities as the payment rates for surgery packages are not updated regularly or based on the actual cost of patient care, Blackmon says. 

Another benefit this change can offer is that practices can potentially avoid duplicative or unwarranted payments when a beneficiary receives post-operative care from a different practitioner during the global period. 

 “Avoiding duplicate payments means avoiding recoupments, which ultimately helps the practice control AR’s,” Blackmon says. However, there is debate if duplicative payments are indeed a challenge. “Currently, duplicate or unwarranted payments are not a huge challenge as most patients understand that if their physician does a procedure on them, they know to go back to the physician that provided the service for their follow up care,” Blackmon says. 

Having no global periods could help you to eliminate disparities between the payment for E/M services in global periods and those that your physician provides individually. “If CMS eliminates the 10-90 day global periods, all codes will be revalued to exclude the services previously included within the global period,” Blackmon says. “When this happens, the practices could benefit by having an increase in office visits being billed to insurance for seeing the patient during a ‘previous’ global period.”

After the transition to 0-day global period, you will be able to maintain the same-day packaging of pre- and post-operative physicians’ services. “This could greatly decrease the number of visits a patient may make to their neurosurgeon. If a patient has to pay to see a specialist, and the co-pays are usually higher, the patient may decide to see their primary care physician and pay lower co-pay,” Blackmon says. 

This CMS proposal may provide more accurate data and support quality research. “CMS would be able to monitor the number of times a patient is seen after a surgical procedure based on the specialty,” Blackmon says. “CMS would in turn make additional adjustments to the allowable amounts based on the data that they find. In the past, with the misvalued code initiative of amendments to the Affordable Care Act, the OIG has found several surgical procedures that included more visits in the global period than are being furnished to patients.”

What this will mean for you? When the revised global period norms will be effective, you will separately bill for the medically reasonable and necessary visits during the pre- and post-operative periods when these are outside of the day of the surgical procedure. “You will need to carefully document the three components of E/M service, specifically the interval history, interval examination, and medical decision making and choose your level of service based on what was performed as well as what was documented,” Przybylski says. 

Learn more: You can read the CMS proposal and find out how to comment at www.federalregister.gov/articles/2014/07/11/2014-15948/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory.

Editor’s note: Stay tuned to Neurosurgery Coding Alert for updates as they come out.