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Did you hear about the changes that are coming down the pike in regards to global services when billing for surgical procedures — be they in the office, in an ambulatory surgical center, or in the hospital?

CMS released their final 2015 Medicare Physician Fee Schedule (MPFS) ruling late last year. Embedded in this document was a proposal by CMS to get rid of both the 10 day and 90 day global periods! In fact, they want to do away with global period billing all together and have all procedures paid based on the work required to do the procedure itself — thereby billing for all post-surgical visits separately using E/M codes.

According to the final ruling, CMS proposes to transform all 10 day global services to ZERO global days starting in 2017. They will do the same in regards to 90 day global services starting in 2018. And, according to the U.S. Department of Health and Human Services (HHS) and the Office of Inspector General (OIG) they have “identified a number of surgical procedures that include more visits in the global period than are being furnished”. They go on to say that they are “also concerned that post-surgical visits are valued higher than visits that were furnished and billed separately by other physicians such as general internists or family physicians”. Based on the final ruling, they plan to begin the transition as previously stated in 2017 after they have considered all comments.

The ruling goes on to state, “as the agency begins revaluation of services as 0-day global periods, we will actively assess whether there is a better construction of a bundled payment for surgical services that incentivizes care coordination and care redesign across an episode of care”. So let’s talk reality and my take on this change.

Over the past few weeks I have read a lot of articles on this subject from various pundits in the industry — they are actually arguing that this change will mean increased reimbursement when you combine the separate payment for the procedure itself along with the visit by visit billing for the post-surgical follow up care when compared to the current reimbursement rate.

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Personally, I think they are all wrong for the following reasons:

Procedure Reimbursement Amount: This is the wild card. They are going to use the same RVU system that has always been used to calculate payment — but I guarantee you the payment for the procedure will not be anywhere near the reimbursement for the global package. I think the closest we could get to estimating the reimbursement rate of the procedure is to figure out what the current surgical care only rate would be (ie. as if you appended Modifier 54 to the procedure code). Beware that this rate would still encompass the pre-surgical evaluation — which I am assuming would be carved out since that is a part of the current global package they are trying to phase out.

Post Op Visits: Getting a patient to comply with medical visits is hard enough — now adding in the fact they would have to pay a copay each time — most often a specialty co-pay is going to make it even harder. Patient’s understand their follow up visits are currently covered in the cost for the surgery, and hence they tend to show up to these visits knowing they do not have any out of pocket expenses. If the proposed change comes to fruition many of the post-surgical visits may become cost prohibitive for a lot of patients and actually lead to a decrease in the number of follow up visits the patient actually schedules. Once the patient starts to feel better their motivation to return dwindles.

Lower Reimbursement Rate for Post-Surgical Visits: It is clearly stated in the CMS ruling that it is felt the post-surgical follow up care visits are paid at a higher rate than what a regular E/M visit would be paid for had the patient been seen by a primary care provider or an internist. That simple statement confirms to me that when the new procedure rate is combined with the individual visit payment rate, the overall reimbursement rate will be less than what is currently being paid.

So, how do you prepare?

First, stay on top of all bulletins coming from CMS in regards to this issue. Most of your medical societies and/or specialty societies have taken clear positions in regards to this matter — so be sure to stay in the loop and become a part of the process.

Run a report that allows you to pinpoint the average number of post-surgical follow up visits for your most billed procedures. This will give you an idea of the average number of follow up visits for particular procedures you know you will bill for if this transition does occur. Does this mean this number will be exact — NO — I would factor in a decrease of 15-20% for visits across the board based on the dynamics I previously described.

Lastly, begin creating a policy in regards to post-surgical follow up care that can act as an education tool for the patient, teaching them the important benefits of being compliant with their post-surgical care schedule and also warning them about the possible increase in out of pocket cost. Being transparent can go a long way into easing patient’s fear and encouraging their follow through.

As always I have included documentation for your library of information — you can find the CMS 2015 MPFS final ruling fact sheet HERE! I also created a brief video presentation on this hot topic HERE.