Spring 2015  

Report to ASCRS on new Surgical Global Packages

Dr. Guy OrangioBy Dr. Guy Orangio

The January meeting of the AMA Specialty Society Relative Value Scale Update Committee (RUC), held in San Diego, CA, highlighted some important information about forthcoming changes in coding and billing, the most significant of which is the implication of changing the Surgical Global Packages to 000 day global.

The Surgical Global Packages
The Final Rule November 2014 from Centers for Medicare and Medicaid Services (CMS) intends to change all current CPT Codes that are 010 or 090 Day Global to a 0 Day Global. The CMS Timeline is 2017 for converting all 010 Day Global Codes to 000 Day Global then in 2018 converting all 090 Day Global Codes to 000 Day Global.

FACTS: Overview
There are 4,267 services on the Medicare Physician Payment Schedule with 010-day or 090-day global period (473 010-day services and 3,794 090-day services). Of these services:

  • 1,156, or 27% had 2013 Medicare utilization greater than 1,000 and only 267 services, or 6%, had utilization greater than 10,000.
  • Only 9% of 010-day global codes have more than one post op office visit.
  • Over 85% of all established patient office visits in 010-day surgical packages are 99212.
  • Only 4% of all 090-day global codes have more than 5 post-operative office visits, and 98% of all established patient office visits in 090-day surgical packages are 99213 or lower.

As far as actual review of codes, assuming that codes with greater than 1,000 Medicare frequencies will meet review criteria: 268-010 (of 473) day codes and 888- 090 (3,794) codes.

The reverse-building block methodology utilized by CMS may not be acceptable because it truly undermines the pre and postoperative work that the surgeon performs. Practice Expense and Professional Liability Insurance can be seriously affected for the following reasons:

  • Direct Practice Expense: There is an extensive list of supplies and equipment that are included in Facility-only services that will not be reimbursed and are not part of a standard E & M service: for example dressing changes, ostomy care, labor surgeons have more LPN, RN than Primary care, etc.
  • Indirect Practice Expense: Will be artificially lowered.
  • Practice Liability Insurance (PLI): There are significant variations between specialty “risk factors” due to the complexities inherent in some surgical services versus some non-surgical services. Currently, the reimbursement for PLI is based on these risk factors and are also based on a “relative scale,” so the higher the risk the higher the factor for reimbursement for the specialty and the procedure. This is not going to be covered at the proper level when the global is “unbundled.” For example, some specialty CPT codes could have up to a 27% decrease in reimbursement for PLI; that is a very serious decrease in reimbursement for PLI.

Removal of the surgical bundles may cause issues with third party payer adoption of the new definition of the global packages.

Other effects of unbundling:

Patient Billing: Patients will be affected, because they will receive a bill for every hospital and office visit during the entire post-operative period, which will mean a co-pay for every office visit. This may cause some patients not to return for follow up after they leave the hospital.

Multiple Surgery Payment Reduction Policy (51 Modifier): This is going to be a serious problem for surgeons. As you all know, if a colectomy is performed and then a small bowel resection or other procedure is performed, Medicare and commercial payers put the highest valued code first than deduct 50% for each CPT code listed after that. The principle behind this modifier is to remove the pre and post operative care from the second to fifth procedure, leaving the WRVU (intra service time) for the procedure, then reimbursed for this work about 50% of the global.

If this rule is left in place, surgeons will be reimbursed a total of 25% of the overall value of the second through fifth codes. This 50% reduction policy will be inappropriate for surgeons.

Copyright © 2015 American Society of Colon and Rectal Surgeons, All rights reserved.