Although an immediate overhaul of the global services reimbursement mechanism has been averted, significant modifications that will affect all surgeons are on the horizon for the coming years.
Global codes include necessary services normally provided by a surgeon before, during, and after a surgical procedure. Global codes are classified as 0-day, 10-day, or 90-day based on the number of postoperative days that will be covered for specific procedures. Approximately 4,200 of the more than 9,900 Current Procedural Terminology (CPT) codes are categorized as either 10- or 90-day global codes.*
This article describes policies by which the Centers for Medicare & Medicaid Services (CMS) would have transitioned all 10- and 90-day global codes to 0-day; the congressional action that prohibited the agency from implementing those policies; the legislation that replaced those policies and will revise global payments in the coming years; and the American College of Surgeons’ (ACS) advocacy efforts.
In July 2014, CMS proposed to transition all 10- and 90-day global codes to 0-day global codes in 2017 and 2018, respectively. Under this proposal, medically reasonable and necessary visits would have been billed separately during the preoperative and postoperative periods outside the day of the surgical procedure. CMS’ rationale behind this policy was concern that the current valuation methodology for global codes is problematic, in that it is based on assumptions about the resources used in furnishing a typical case for each individual service rather than actual data on the cost of furnishing services. CMS also questioned whether the values included in the postoperative global codes reflect the care actually furnished during that period. CMS’ proposal did not include a methodology for making this transition, nor did it provide an analysis of its impact on surgical patients or the surgeons who care for them.
Although initially it appeared that this proposal could benefit surgeons, given that they would be able to bill separately for each follow-up visit, an analysis by the ACS General Surgery Coding and Reimbursement Committee (GSCRC) showed that this policy would result in a decrease in payments to surgeons. This reimbursement reduction is attributable to separately reportable evaluation and management (E/M) codes being reimbursed at a lower rate than the E/M codes included in the value of global codes. Furthermore, the separately reportable E/M services would not cover the practice expenses and liability costs associated with postoperative visits. In addition, some postoperative work now included in 10- and 90-day global surgical packages is unreportable through E/M codes; thus, depending on the methodology that CMS would have used, surgeons might not have been paid for some follow-up care.
Based on these findings, in September 2014 the ACS submitted a detailed comment letter to CMS describing these and other reasons why the agency should refrain from implementing the policy. In the letter, the College stated that CMS first should complete a comprehensive analysis of the effect the policy would have on surgical patients and on access to surgical care, and develop a methodology for making the transition to 0-day global codes. Without a transparent methodology, it would be impossible for stakeholders to provide cogent feedback to CMS on the validity and viability of its proposed policy. Despite these and other efforts by the ACS regulatory staff to counter the policy, in November 2014, CMS finalized the policy to transition 10- and 90-day global codes to 0-day.
Before finalization of this policy, the ACS GSCRC also embarked on an extensive data analysis and modeling project to estimate the impact of a transition to 0-day global codes. The findings from this project were used to support recommendations to CMS on how to develop a fair and accurate methodology for transitioning to 0-day global codes if the agency intended to move forward. GSCRC and ACS staff presented these recommendations to CMS in meetings with senior CMS officials in February and April 2015.
In parallel with its regulatory efforts, the College’s legislative and political team spent several months working to bring about a legislative solution to the problems associated with CMS’ proposal to eliminate 10- and 90-day global codes. During Congress’ lame-duck session following the November 2014 election, a coalition of surgical groups led by the College provided legislative language to lawmakers for inclusion in the catchall omnibus spending bill. The language would have precluded CMS from moving forward with its plan to transition 10- and 90-day global codes to 0-day global codes. However, despite strong support from a group of physicians in the House of Representatives known as the congressional Doctors Caucus and other representatives, the language was omitted from the final legislation.
When Congress reconvened in January, the College redoubled its efforts to ensure this policy was not permitted to take effect. Reps. Larry Bucshon, MD, FACS (R-IN), and Ami Bera, MD (D-CA), drafted a letter to House Speaker John Boehner (R-OH) and Minority Leader Nancy Pelosi (D-CA), urging them to take action to nullify CMS’ plan. Dr. Bucshon, a cardiothoracic surgeon, and Dr. Bera, a family physician, worked to encourage other House members to sign on to the letter, making sure the issue rose to a priority level in Congress (see comment by Representative Bucshon below). The letter ultimately garnered strong support. Due to the hard work and determination of surgical champions in Congress, this issue remained on the table throughout negotiations on the bipartisan Medicare reform legislation, and was included in the final package that was passed by overwhelming margins in the House and Senate. This significant legislative victory was made possible through the continuous efforts of Drs. Bucshon and Bera and other members of the Doctors Caucus, including Reps. Tom Price, MD, FACS (R-GA); Dan Benishek, MD, FACS (R-MI); and Charles Boustany, MD, FACS (R-LA); as well as Phil Roe, MD (R-TN), chairman. The ACS’ advocacy efforts were ultimately successful when President Barack Obama signed the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA) into law on April 16. This law not only repealed the sustainable growth rate (SGR) formula used to calculate Medicare physician payments, but it also prevented CMS from implementing the policy to transition 10- and 90-day global codes to 0-day.
With MACRA in place, beginning on or before January 1, 2017, CMS is required to collect the data needed to value surgical services from a representative sample of physicians. These data must include information on the number and level of medical visits furnished during the global period and on other appropriate items and services related to surgery furnished during the global period. MACRA also allows 5 percent of the surgical payments to be withheld until these data are reported at the end of the global period and grants authority to discontinue the reporting requirement if sufficient information can be derived from Qualified Clinical Data Registries, surgical logs, electronic health records, or other sources. Beginning in 2019, CMS must use these and possibly other data that the agency might identify to improve the accuracy of the valuation of surgical services.
The hard-fought victory for both the repeal of the SGR and blocking the implementation of the global services transition policy was achieved through the advocacy efforts of the ACS and other medical associations, Fellows’ participation in meetings with lawmakers, and thousands of letters and calls to Capitol Hill.
The future for global surgical services
As the law currently states, CMS is prohibited from implementing its policy to transition 10- and 90-day global codes to 0-day global codes, but the agency is required to collect data on global services starting no later than January 1, 2017, and use those data to revise global services starting in 2019.
The ACS will continue working to influence the implementation of this new global payments policy. Efforts will include developing recommendations for CMS on the methodology for collecting data, as the methodology used by CMS is directly relevant to the type of data that will be gathered. The ACS will then put forth recommendations on how these data should be used to revalue global surgical services in 2019. The ACS GSCRC will continue to collaborate and build on its relationship with CMS to ensure that the agency implements the MACRA-mandated revisions to global services in a fair and accurate manner.
More information about CMS’ sidelined proposal to transition global payments and the revisions mandated under MACRA is available on the ACS website.
*All specific references to CPT (Current Procedural Terminology) codes and descriptions are © 2014 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.