Ophthalmology and Optometry Coding Alert

You could charge separate E/M, in many cases.

A big surprise hit the presses in a recent proposed rule for the Medicare Physician Fee Schedule (PFS). CMS proposes severely cutting global periods for surgical procedures — a move that could impact pay for many procedures that your ophthalmologist performs. 

Although the proposal is not firm and would not go into effect until 2017, your practice should learn the facts now so that you can look out for your future bottom line. 

Eliminate 10- and 90-Day Global Periods

You might be surprised to learn what CMS is suggesting. “We are proposing to transform all 10- and 90-day global codes to 0-day global codes beginning in CY 2017,” CMS says in a fact sheet about the fee schedule proposal.

Why? “The OIG has identified a number of surgical procedures that include more visits in the global period than are being furnished.” Because CMS seems to believe that Medicare is wasting cash by paying doctors for global periods that include visits the doctors don’t actually perform, CMS is proposing to include “all services provided on the day of surgery, and to pay separately for visits and services actually furnished after the day of the procedure …” CMS says in its fact sheet.

Impact: This would mean that you could bill any postoperative services on an a la carte basis instead of bundling all related post-operative care into the surgical charge. 

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.”

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.

Review Current Practices

Currently, your ophthalmic surgeon 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 to procedures like endoscopies and other minor surgeries. For these procedures, there is no pre-operative or post-operative period, but you can’t separately bill a non-medically necessary separate 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. No pre-operative period 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 procedure provided during the post-operative period that is related to the recovery from the surgery, including pain management.