Potential Changes for Global Package

By Maryann C. Palmeter, CPC, CENTC
In the calendar year 2015 Medicare Physician Fee Schedule Proposed Rule (Federal Register Vol. 79, No. 133/Friday, July 11, 2014), the Centers for Medicare & Medicaid Services (CMS) addressed some concerns with global surgical packages, in particular the 10-and 90-day post-operative global packages. CMS expressed concern that they cannot effectively address the issues inherent in establishing values for the 10- and 90-day global packages under exiting payment methodologies because the valuation process for physician fee schedule services generally relies on assumptions regarding the resources involved in furnishing the “typical case” for each individual service unlike other payment systems that rely on actual data on the costs of furnishing services.  CMS believes that the typical number and level of post-operative visits during global periods may vary greatly across Medicare practitioners and patients.
CMS is proposing to retain global bundles for surgical services, but to refine bundles by transitioning over several years all 10- and 90-day global codes to 0-day global codes. Medically reasonable and necessary visits would be billed separately during the pre-and post-operative periods outside of the day of the surgical procedure.  CMS is proposing to make this transition occur in calendar year 2017 for the current 10-day global codes and in calendar year 2018 for the current 90-day global codes.
CMS sought input from stakeholders on the typical number of E/M and other services furnished during the current post-operative periods to appraise particular services necessary to implement this proposal and address overall budget neutrality. CMS also sought input on the best way to ensure that allowing separate payment of post-operative E/M visits does not incent otherwise unnecessary office visits during post-operative periods.
Currently, if a surgical procedure with a 10- or 90-day post-operative period is billed, related E/M services within those respective post-operative periods are included in the payment for the surgical procedure. Medicare pays 80% of the physician fee schedule amount if the procedure is performed by a physician even though the post-operative visits may be performed by a nonphysician practitioner. Furthermore, Medicare will pay 80% of the physician fee schedule amount for the global surgery package if the post-operative visits are performed by a resident under the supervision of a teaching physician as long as the teaching physician is present during all critical and key portions of the surgical procedure and immediately available to furnish services during the entire procedure. Although the teaching surgeon is responsible for the preoperative, operative, and postoperative care of the patient, the teaching surgeon determines which postoperative visits are considered key or critical and require his or her presence. In appropriate cases, there may be no key post-operative visits and an unreduced fee may be billed as long appropriate care is provided by a resident. In order to bill for E/M services performed outside of the global surgical package, the teaching physician must personally document at least the following:

  • That they performed the service or were physically present during the key or critical portions of the service when performed by the resident; and


  • The participation of the teaching physician in the management of the patient.

If the teaching physician does not comply with the above requirements, the E/M service may not be billed to Medicare.
If a qualified nonphysician practitioner performs an E/M service and bills Medicare directly for the service, Medicare will reimburse at 85 percent of the physician payment rate.
So the question is, what impact will carving out post-operative visits from the global surgical package have on your practice if you utilize residents in post-operative clinics? Do your teaching physicians currently see every post-operative patient? Will you need to adjust teaching physician coverage schedules?
What impact will this change have on your practice if you utilize nonphysician practitioners in post-operative clinics? Will your reimbursement for post-operative visits be reduced by 15%? Could a post-operative visit be billed incident-to a physician?
I’d love to hear your thoughts.

Maryann Palmeter

About Has 23 Posts

Maryann C. Palmeter, CPC, CPCO, CPMA, CENTC, CHC, has more than 30 years of technical and executive level experience gained through her work on both the government payer and professional billing ends of the healthcare spectrum. She is director of physician billing compliance at the University of Florida Jacksonville Physicians, Inc., and is responsible for providing professional direction and oversight to the billing compliance program of the University of Florida College of MedicineJacksonville. Palmeter served on the AAPC’s National Advisory Board from 2011-2013 and was subsequently selected to serve as secretary for the 2013-2015 term. She was named the AAPC’s 2010 “Member of the Year” and is the vice president for the Jacksonville, Fla., local chapter.

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