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Sometimes it’s difficult to figure out which way is forward. For the past few years, private insurers and the federal government (through the Medicare program) have been experimenting with and putting in place different ways of paying physicians for the care they provide. Many alternatives are designed to increase value for our nation’s health care dollars and improve quality of care, often through care coordination. Most involve different ways of “bundling” care—paying a single sum for a patient’s episode of care rather than separate payments each time a physician encounters a patient.
For more than 20 years, Medicare has bundled most surgeries, paying 1 sum to the physician and requiring only 1 copayment from the beneficiary patient. In this way, when a patient needs surgery, Medicare pays the surgeon 1 payment for preparation the day before surgery, for the surgery itself, and for either 10 or 90 days of follow-up care, depending on the specific procedure involved (TABLE 1). Similarly the patient has had 1 copay for the entire episode of care. This bundling is called global surgical codes, and it applies to coding, billing, and reimbursement.
Table 1: CMS description of 10- and 90-day global codes Minor procedures: 10-day postoperative period
Major procedures: 90-day postoperative period
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This approach may change soon—and not for the better. In this article, I describe how the federal Centers for Medicare and Medicaid Services (CMS) plan to eliminate global surgery bundling, as well as the efforts under way by the American Congress of Obstetricians and Gynecologists (ACOG) and other organizations to stop the proposed change.
The CMS plan to eliminate surgical bundling
In a significant twist from the trend toward bundling and care coordination, CMS finalized its proposed policy in its 2015 Medicare Physician Fee Schedule final rule to transition all 10- and 90-day global surgical codes to 0-day global surgical codes by 2017 and 2018, respectively. Beginning in 2017 for 10-day global codes and 2018 for 90-day codes, physicians will be paid separately for the day of surgery and for evaluation and management (E&M) provided on the day before and any days after. Patients will have copays for each physician intervention.
CMS has decided to move forward with this change despite overwhelming concern and opposition on the part of both patients and physicians. This change would affect more than 4,200 services on the Medicare Physician Fee Schedule—well over one-third of the 9,900 current procedural terminology (CPT) codes.
The new codes and increased paperwork and billing are daunting, and would result in an estimated 63 million additional claims per year to account for postsurgical E&M services. The cost to CMS alone for this huge new mountain of claims may be as high as $95 million per year. Moreover, under the new system, patients may not return for the full range of follow-up care needed if they get billed for every visit, possibly resulting in poorer outcomes.
CMS’ justification for unbundling
CMS argues that this change is needed because many surgeons are failing to provide as much care (as many E&M follow-up visits) as they’re paid to deliver under the 10- and 90-day codes. As evidence, CMS points to 3 reports published by the Department of Health and Human Services Office of Inspector General:
- An April 2009 report from the field of ocular surgery found that physicians provided fewer E&M services than were included in 201 of 300 examined global surgery fees. The cost of these undelivered services was approximately $97.6 million.1
- A May 2012 report from the field of cardiac surgery found that physicians provided fewer E&M services than were included in 132 global surgery fees of the 300 surgeries examined. The cost: $14.6 million.2
- Another May 2012 report, this one from the field of musculoskeletal surgery, found that physicians provided fewer E&M services than were included in 165 global surgery fees of the 300 surgeries examined. The cost for these undelivered services: $49 million.3
Based largely on these reports, CMS has determined that it cannot verify the number of visits, level of service, and relative costs of the services included in a global package, in large part because the current valuation methodology relies on survey data estimating the resources used in a typical case, instead of on actual data.
