November 24, 2014

CMS has raised hackles in the physician community by finalizing its proposal to eliminate 10- and 90-day global surgical periods beginning in 2017 (Final Fee Schedule Rule).  All procedures would have a zero-day global period by 2018.  While the change will not affect anesthesia services or most pain medicine practices, it is of great concern to surgeons—and their anesthesiology colleagues should therefore be conversant with the issues.

The Global Surgical Package

The global surgical package includes all necessary services normally furnished by a surgeon before, during and after a procedure.  Medicare payment for the surgical procedure includes the preoperative, intra-operative and postoperative services routinely performed by the surgeon or by members of the same group with the same specialty, whether provided in the inpatient, outpatient, ambulatory surgery center (ASC) or office setting.  There are no global periods for anesthesia services, but most pain medicine procedures are subject to the policy.

There are three types of global surgical packages based on the number of post-operative days, as shown in the table below:

A visit on the day of the procedure is generally not payable as a separate service for any of these global periods.  Thus the total global period is in effect 11 days for 10-day procedures (day of procedure plus ten post-op) and 92 for 90-day procedures.  For complete information on the global surgical package, see Chapter 12, Section 40 and 40.1 of the Medicare Claims Processing Manual.

What the elimination of the 10- and 90-day global periods will mean is that the payment for the affected procedures will come down.  The relative value units for each procedure are calculated based on including the following in the total payment amount:

• Preoperative visits after the decision is made to operate;
• Intra-operative services that are normally a usual and necessary part of the procedure;
• All additional medical or surgical services provided by the surgeon during the global period because of complications that do not require a return to the operating room;
• Follow-up visits during the global period that are related to recovery from the surgery;
• Postoperative pain management by the surgeon;
• Supplies, except for identified exclusions, and
• Miscellaneous services such as dressing changes, removal of sutures and staples, etc.

CMS decided to make all procedures zero-day because the Office of the Inspector General has identified a number of surgical procedures that include more visits in the global period than are being furnished in fact and on average.

Objections to the Change

How do you calculate the value of each of the above components for every procedure with a 10- or 90-day global surgical period?  Numerous medical organizations that filed comment letters on the Proposed Fee Schedule Rule published in the Federal Register in July raised that question.  The American Medical Association noted the following principal objections in its August 29, 2014 letter to CMS Administrator Marilyn B. Tavenner:

1. More than 4,200 services on the Medicare Physician Payment Schedule have 10-day or 90-day global periods.  Unbundling each of these services from its included postoperative visits and services, and determining relative values not just for physician work but also for practice expenses and malpractice costs, will take a great deal of time and effort for a relatively small cost savings.
2. Unbundling the global surgical packages will require new codes and valuation to permit providers to report postoperative services.
3. The level of visit will likely rise, and Medicare costs increase, because on average, the global surgical packages have much lower levels of office and hospital visits than separately-reported visits.  Only one percent of all established patient office visits in 010-day and 090-day global surgery packages have a visit level above a 99213, whereas 43 percent of all separately-reported office visits are reported as a 99214 or 99215.
4. Physicians will submit, and CMS will need to process, millions of separate claims for postoperative services currently included.  Individual commercial health plans may or may not do away with the global surgical package, or they may do so on a different timetable.  The resulting “heterogeneous reporting mechanisms between payers” could create a huge administrative burden.
5. Unbundling postoperative services will result in patients having to pay co-payments for each visit, instead of a single global package co-payment.  An additional co-payment per visit may incentivize many patients to skip follow-up visits in order to save money.

Other organizations including the American Society of Anesthesiologists and the American College of Surgeons submitted letters echoing the AMA’s concerns.  The Medical Group Management Association added a philosophical point:  “CMS is also exploring increased use of bundled payments in Medicare, including the Bundled Payments for Care Improvement Initiative.  It is completely contradictory for the agency to tout the benefits of bundled payments, such as increased accountability, while simultaneously proposing to abandon the use of long-standing bundled payments under the current proposal.”

A coalition of surgeons’ organizations is now forming to oppose or at least delay the elimination of the 10- and 90-day global periods.

Pain Medicine Procedures with 10-Day and 90-Day Global Periods

As noted above, anesthesia codes do not have global days.  The placement of invasive monitoring lines, transesophageal echocardiography and other non-anesthesia procedures performed by anesthesiologists are also either 000 day procedures or are not subject to the global policy.  Pain medicine procedures with global periods of either ten or ninety days are listed below:

The dollar impact of the unbundling of postoperative services is not yet known.  It is possible, although perhaps not likely, that CMS will be persuaded to rethink the elimination of the ten-day global periods which is currently set to happen on January 1st, 2017.  Two years is not a long time to do the data collection, analysis and stakeholder consultation involved in such a change.  In any event, we will keep you informed, as always.

With best wishes,

Tony Mira
President and CEO