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FEDERAL | CMS to Require Reporting of Post-Op Care Under Global Surgery Codes

Last week, The Centers for Medicare and Medicaid Services (CMS) issued a final rule outlining changes it will implement to next year’s Physician Fee Schedule (PFS). The updates will impact payment not just for doctor visits and diagnostic testing, but also for surgery.

Under the PFS, surgical services are valued and paid for as part of global packages that include the procedure and the services typically furnished in the periods immediately before and after the procedure. For each of these global packages, CMS establishes a single PFS payment that includes payment for services that they assume to be typically furnished during the established "global period."

Three recent Office of the Inspector General reports have indicated the global surgery payment is often over-reimbursed, since many patients do not receive the total number of post-op visits that, based on historical data, were used to help determine the rate setting for global surgery payments. Because CMS has never required claims reporting of visits included in the global surgical package, they had no information on the number or types of services provided in the post-op period.

To value global packages accurately and relative to other procedures, earlier this year the Agency proposed to collect information about the resources – work, practice expenses and malpractice costs – used in furnishing the procedure, similar to what is used to determine RVUs for all services.

That initial proposal included requirements for reporting post-op care, based on 10-minute increments, to be reported for each and every surgical CPT code. Advocacy efforts by ASPS and other medical specialty societies, as well as the AMA, resulted in the Agency agreeing to allow CPT code 99024 to be reported instead.

While all surgeons are encouraged to submit claims for post-op care next year, reporting of those visits will be mandatory only for services related to codes identified as having been reported annually by more than 100 practitioners. Additionally, only those codes reported more than 10,000 times or have allowed charges in excess of $10 million annually will be included in this mandate.

Based on ASPS staff analysis, Plastic Surgeons who bill the following codes may be impacted:

CPT CodeDescription
15734 Muscle, myocutaneous, or fasciocutaneous flap; trunk
15732 Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg., temporalis, masseter muscle, sternocleidomastoid, levator scapulae)
15100 Split-thickness autograft, trunk, arms, legs; first 100 sq. cm or less, or 1% of body area of infants and children (except 15050)
15120 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq. cm or less, or 1% of body area of infants and children (except 15050)
14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq. cm or less
14040 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq. cm or less
11643 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm
14301 Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq. cm to 60.0 sq. cm
11442 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm
14020 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq. cm or less
14021 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq. cm to 30.0 sq. cm
15240 Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq. cm or less
11644 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm.

However, CMS has yet to publish the final list of CPT codes that will be impacted. Additionally, and based on their analysis of beneficiaries across various geographic areas of the country, CMS has determined reporting will be mandated for only those practitioners who practice in groups of 10 or more practitioners, and are located in the following states:

Surgeons are encouraged to begin reporting post-operative visits on or after January 1, 2017, but the mandatory requirement to report will be effective for services related to global procedures furnished on or after July 1, 2017.

On a positive note, the final rule indicates physician payment rates will increase by 0.24 percent in 2017. The agency has also revised the system used to calculate geographic practice cost indices. This methodology adjusts payments to reflect geographic differences in practice costs. These updates will be phased in over 2017 and 2018.