Data Collection Requirements for Post-op Visits
Under the Medicare Physician Fee Schedule (PFS), certain services (such as surgery) 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, the Centers for Medicare & Medicaid Services (CMS) establishes a single PFS payment that includes payment for particular services that the agency assumes is typically furnished during the established global period.
The Social Security Act requires CMS to develop, through rule-making, a process to gather information needed to value surgical services from a representative sample of physicians, and requires that the data collection begin no later than January 1, 2017.
In the CY 2015 PFS proposed and final rules, CMS discussed the problems with accurate valuation of 10- and 90-day global packages.
CMS finalized a policy to transform all 10-day and 90-day global codes to 0-day global codes in CY 2017 and CY 2018, respectively, to improve the accuracy of valuation and payment for the various components of global packages including pre- and postoperative visits and the procedure itself.
This policy was overturned with MACRA.
To gain additional input from stakeholders on implementation of this data collection, CMS sought comment on various aspects of this requirement in the CY 2016 PFS proposed rule. Furthermore, CMS sought comment from the provider community via subsequent listening sessions and contracted with the Rand Corporation to determine the best way to collect the needed data.
Although CMS believes that most of the services furnished in the global period are visits for follow-up care, they do not have accurate information on the number and level of visits typically furnished because those billing for global services are not required to submit claims for post-operative visits.
Procedure code 99024 Postoperative follow-up visit, normally included in the surgical package, to indicate than an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure does not tell CMS what level of service was provided or the resources utilized during the post-op period.
CMS needs to know the volume and costs of the resources typically used to properly value global surgical packages.
CMS proposed a three-prong approach to collect needed data:
- Comprehensive claims-based reporting about the number and level of pre- and post-op visits furnished for 10- and 90-day global services.
- A survey of a representative sample of practitioners about the activities involved in and the resources used in providing a number of pre- and postop visits during a specified, recent period of time, such as two weeks.
- A more in-depth study, including direct observation of the pre- and postop care delivered in a small number of sites, including some Accountable Care Organizations.
For claims reporting, CMS proposed new HCPCS Level II codes that would be reported for services related to, and within 10- and 90-day global periods for, procedures furnished on or after January 1, 2017. Services related to the procedure furnished following recovery and otherwise within the relevant global period would be required to be reported. These codes would be included on claims filed through the usual process.
Inpatient Post-op Visits
|Inpatient||GXXX1||Inpatient visit, typical, per 10 minutes, included in surgical package.|
|Inpatient||GXXX2||Inpatient visit, complex, per 10 minutes, included in surgical package.|
|Inpatient||GXXX3||Inpatient visit, critical illness, per 10 minutes, included in surgical package.|
It is expected that the vast majority of inpatient post-op visits would be expected to be reported using the GXXX1 code.
Activities in Typical GXXX1 Visits (as well as Office/Outpatient GXXX5 Visits)
|Review vitals, laboratory or pathology results, imaging, progress notes
|Remove stitches, sutures, and
|Take interim patient history and evaluate post-op progress
|Assess bowel function
|Counsel patient and family in person or via phone
|Manage medications (for example, wean pain medications)
|Contact/coordinate care with referring physician or other clinical staff
|Complete forms or other paperwork
In addition to GXXX1, there are two other code options for inpatient post-op visits:
- Inpatient pre- and post-operative visits that are more complex than typical inpatient visits but do not qualify as critical illness visits would be coded using GXXX2.
- The service provider would be required to furnish services beyond those included in a typical visit and have documentation that indicates what services were provided that exceeded those included in a typical visit.
- Highest level of inpatient pre- and post-operative visits, critical illness visits.
- Report when the physician is providing primary management of the patient at a level of care that would be reported using critical care codes if it occurred outside of the global period.
- Involves acute impairment of one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.
Office and Other Outpatient Post-op Visits
|Office/ Other Outpatient||GXXX4||Office or other outpatient visit, clinical staff, per 10 minutes, included in surgical package.|
|Office/ Other Outpatient||GXXX5||Office or other outpatient visit, typical, per 10 minutes, included in surgical package.|
|Office/ Other Outpatient||GXXX6||Office or other outpatient visit, complex, per 10 minutes, included in surgical package.|
- Used for reporting post-op visits in the office or other outpatient settings.
- For these three codes, time would be defined as the face-to-face to-face time with patient, which reflects the current rules for time-based outpatient codes.
- GXXX4 would be used for visits in which the clinical care is provided by clinical staff.
- It is expected that the vast majority of office or other outpatient visits would be expected to be reported using the GXXX5 code.
- GXXX6 expected to be used infrequently.
Only face-to-face time spent by the practitioner with the patient and their family members counts toward the time reported with the office visit codes.
Services Furnished Via Electronic Means
|GXXX7||Patient interactions via electronic means by physician/NPP, per 10 minutes, included
in surgical package
|GXXX8||Patient interactions via electronic means by clinical staff, per 10 minutes, included in surgical package.|
- Do not report GXXX7 or GXXX8 if they are furnished the day before, the day of, or the day after a visit, as this would be included in the pre- and post-service activities in the typical visit.
- Use GXXX7 or GXXX8 for non-face-to-face services provided by clinical staff prior to the primary procedure since global surgery codes are typically valued with assumptions regarding pre-service clinical labor time.
For services furnished via interactive telecommunications that meet the requirements of a Medicare Telehealth service visit, the appropriate global service G-code for the services should be reported with the GT modifier to indicate that the service was furnished ‘‘via interactive audio and video telecommunications systems.’’
The submission of these G-codes for post-op visits associated with surgeries having 10- or 90-day post-op period is not optional.
- CMS is authorized to withhold payment of up to 5% of the payment for services on which the practitioner is required to report, until the practitioner reports.
- CMS will not implement this option at this time but may change if compliance with claim-based reporting is not acceptable.
- CMS believes that it is beneficial to practitioners to report this information so that appropriate revisions can be made when CMS revalues global service payments.
Final policy and HCPCs Level II codes are expected sometime in November when the CY 2017 PFS Final Rule is usually published, so stay tuned.