Important Information on the Global Surgery Period Modification Rule

Earlier this week the American College of Surgeons sent an email urging all Fellows to take action and contact their US House Representatives in an effort to preserve global payments in response to the Centers for Medicare & Medicaid Services (CMS) policy to transition 10- and 90-day global codes to 0-day global codes by 2017 and 2018, respectively. Based on feedback and questions we have received, below our email please find in-depth information clarifying the ACS strategy and rationale.

Due to the gravity of this policy the College has put substantial time and thought into this matter. While this transition may sound appealing at first glance, this plan has a number of significant downsides for both patients and surgeons. (See detailed explanation below this message.)

We still encourage you to take action on this important issue (log in using your Member number), and help us ensure that Congress intervenes in a timely manner. Please feel free to reach out to us with any additional questions, concerns, or requests for information.

Sincerely,

Andrew L. Warshaw, MD, FACS
President, ACS

Mark C. Weissler, MD, FACS
Chair, ACS Board of Regents

Michael J. Zinner, MD, FACS
Chair, ACS Health Policy and Advocacy Group

David B. Hoyt, MD, FACS
Executive Director, ACS

In-Depth Analysis:

As a reminder, under the current system, Medicare pays surgeons and other specialists a single fee when they perform a global service. This single fee covers the costs of the surgery plus all follow-up care on the day of surgery or within a 10- or 90-day timeframe. The surgeon gets one payment and the Medicare beneficiary only pays a single co-pay. Under the agency’s new approach, surgeons will be paid only for the surgery and all follow-up visits will have to be billed and paid as separate payments. There are a number of substantial problems for both patients and surgeons in this policy transition:

    • Some post-operative work now included in 10- and 90-day global services is not reportable through E&M codes. Depending on how CMS changes existing policy, surgeons may not be paid for some follow-up care. If 10- and 90-day global codes are transitioned to 0-day, there will be no way to bill items and services, such as:
      • Dressing changes, removal of packing, and local wound care;
      • Insertion, irrigation and removal of urinary catheters;
      • Routine peripheral intravenous lines;
      • Nasogastric and rectal tubes; and
      • Changes and removal of tracheostomy tubes.

 

    • Separately reportable E&Ms will not cover the practice expenses of most surgeons for their post-operative visits. In essence, surgeons will be paid less for the same post-operative follow-up care. Even if it were possible to unbundle global codes in an accurate way, the separately reportable E&Ms are lower in value than the E&Ms that are included in global codes. This is because the E&Ms that are part of global codes include additional, justifiably more expensive supplies and equipment compared to standard, separately reportable E&Ms. Examples of supplies/equipment that fall into this category are specialized bandages and dressings, different postoperative surgical care packs, as well as specialized examination tables, cast cutters, and surgical and exam lights.

 

    • CMS has not provided a methodology for transitioning 10- and 90-day global codes to 0-day. CMS has stated that this transition will occur, but has not explained how it plans to go about making the transition. As such, there is no way to truly know the consequences of this policy. However, it is clear that the administration believes that this is a way to save a significant amount of money.  Because CMS has not provided a plan for this change, whatever transition occurs has the potential to dramatically DECREASE payments to surgeons. The values for global services were determined by looking at the entire package, not by valuing the individual components and summing them. As such, it is not possible to simply “back out” the post-operative E&Ms from a global service to calculate the accurate value of the procedure itself.

 

  • Existing CMS policies will inappropriately reduce payment of 10- and 90-day global codes. CMS currently reduces payment for multiple procedures, assistants at surgery, bilateral surgery, and co-surgery, based upon the values and time frame of 10- and 90-day global periods. Major cuts to these services would occur if 10- and 90-day global codes are transitioned to 0-day.

For example, the multiple procedure payment reduction policy reduces the second and other procedures by 50%, and reduces the third through the fifth procedures by 75% due to the overlap of bundled E/M services between the surgeries. If 10- and 90-day global codes are transitioned to 0-day, CMS has not stated there will be any payment policy changes to this rule, thus reducing payment even more for those multiple procedures.

The same would happen to surgical assistant’s fees, which are now based upon 16% of the 10- or 90- day global code value. CMS has not said that they will alter this 16% payment, even though the 0-day global payment will be reduced under their new policy.

    • This policy could negatively impact patient access to quality surgical care. Requiring patients to pay a copay for each follow-up visit instead of one copay for the entire global service could dissuade them from returning for follow up care and could adversely affect surgical outcomes. This would disproportionally affect the sickest patients who require more follow-up care than is currently bundled into global payment.

 

  • This policy will cut payments for malpractice insurance that is included in global codes. CMS includes malpractice insurance as part of the global payment, but this malpractice payment will be reduced substantially if 10- and 90-day global codes are transitioned to 0-day.
  • This will dramatically increase administrative burden. It is estimated that this policy will lead to an additional 63 million claims from surgeons to CMS each year. That means more work for already strained surgical billing offices.

These are just some of the numerous implementation problems, unintended consequences, and issues to be addressed if CMS moves forward with this policy. If surgeons would be paid accurately for the work that they do under this policy of unbundling global codes, then the ACS would not be calling for it to be rescinded; however, as this policy currently stands, it has significant downsides to surgeons and surgical patients.