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AANS Neurosurgeon : Coding Clarity

Volume 24, Number 2, 2015

How H.R. 2 Affects Global Periods

John Ratliff, MD, FAANS

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On April 14, 2015, the U.S. Senate passed H.R. 2, The Medicare Access and CHIP Reauthorization Act, which finally fixed the Sustainable Growth Rate (SGR), after 14 years of threats to physician reimbursement. The act also overhauled the Physician Quality Reporting System (PQRS), replacing it with a new Merit-Based Incentive Payment System (MIPS).

So what does H.R. 2 mean for physician reimbursement? In the near term, it prevents a 21-percent reduction in Medicare reimbursement that was threatened by the previous SGR legislation, the same threatened cuts that had produced nearly 20 previous “patches.” In the near-term, the 21-percent reduction is prevented, and physician reimbursement is provided a 0.5-percent increase for the remainder of 2015 and each additional year through 2019.

The Effect on Surgical Global Periods
I want to touch on how this bill impacted surgical global periods as well — the topic of the last two editions of Coding Clarity.

What a huge difference a little time makes. For the previous two editions of Coding Clarity, we reviewed what a global period is and what is and is not included in a global. This is of significant general use to practicing surgeons, since so much of what we do is procedure-based: either getting patients prepared for surgery, doing surgery or taking care of patients in the early period after surgery. With the global period, your post-op hospital and clinic visits are already paid for in the single payment for the procedure.

With that previous background and those definitions in place, I thought I had my readership well prepared to appropriately capture their physician work and to appropriately decide what is and what is not included in a global period for a given surgery.

Then, in November 2014, the 2015 Medicare Physician Fee Schedule (MPFS) came out and threatened to scupper all of that work, and to toss out the definition of a “global period” altogether. The 2015 MPFS proposed a radical change in how surgery is paid for, with elimination of the 10- and 90-day global periods.

The Impact on Physicians
This is a big deal. The Evaluation and Management (E&M) services provided after surgery can routinely account for up to 40 percent of a given surgical code’s value. This also would have engendered need for documentation of every single post-op visit provided during a patient’s hospitalization and post-op, 90-day period. Needless to say, the administrative burden would be enormous, with huge amounts of additional billing required by individual physicians as they document the post-operative care they provide.

So why did the Centers for Medicare and Medicaid Services (CMS) want to do this? CMS thinks that some physicians are not providing the post-operative care that they are being paid for with the 90-day global payment. So, CMS proposed scrapping the global period altogether and having surgeons bill for their post-op care the same way they would bill for routine evaluation and management (E&M) services. The deadline CMS set for instituting this change is 2017 for 10-day globals and 2018 for 90-day globals.

This produced nightmares at the RBRVS Update Committee (RUC), the body that advises CMS on the values of given procedures: This dictum was essentially a mandate to revalue the entire fee schedule. The simplest approach would be to subtract out the value of the E&M services that would be eliminated with elimination of the global period. This does not work in most codes and creates a number of codes that would have negative values; that approach would not work.

Facing Additional Changes
Then it all changed. Again.

H.R. 2 also included a provision to reverse the proposed elimination of the 10- and 90-day global periods. So, the global period (at least for now) will remain, and the need for extensive additional documentation is avoided. H.R. 2 mandates that CMS will begin collecting data on the number of hospital and clinic visits required post-operatively in some procedures. This will begin in 2017 and may require an increase in documentation. Following how this new legislation is implemented will keep your Washington Committee and Coding and Reimbursement teams busy for the next few years.

I did not plan on doing an additional column on global periods, but with these recent changes, further explanation was necessary. I hope in the upcoming issues to get back to some more basic coding questions that impact membership.

The American Association of Neurological Surgeons (AANS) remains dedicated to providing accurate, timely coding and reimbursement education and support to members. If you have any questions or concerns, please do not hesitate to contact me or any member of the Coding and Reimbursement Committee for help.

John Ratliff, MD, FAANS, is an associate professor of neurosurgery at Stanford University School of Medicine, where he also is co-director of the division of spine and peripheral nerve surgery. Dr. Ratliff is the RBRVS Update Committee advisor for the AANS and co-director of the AANS Managing Coding and Reimbursement Challenges in Neurosurgery courses. In addition, he serves as vice chair for the joint CNS/AANS Quality Improvement Workgroup, and is a member of the AANS Neurosurgeon Editorial Board. The author reported no conflicts for disclosure.


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