Coders Beware: CMS Surgical Audits Began July 1

Coders Beware: CMS Surgical Audits Began July 1

Be sure to provide adequate clinical documentation to support 99024.

By Barbara Aubry, RN, CPC, CPMA, CHCQM, FABQAURP

As of July 1, the Centers for Medicare & Medicaid Services (CMS) began auditing claims for nearly 300 targeted services to determine whether CPT® 99024 Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure is being used correctly to report post-operative follow-up services provided and prepaid as part of the global surgery fee. The audits are a wake-up call to all practices and facilities reporting evaluation and management (E/M) services during a global period.

Evaluation and Management – CEMC

Audits Arise from OIG Recommendations 

On May 1, 2012, the Office of Inspector General (OIG) released audit findings (A-05-09-00053) titled “Musculoskeletal Global Surgery Fees Often Did Not Reflect the Number of Evaluation and Management Services Provided.” The audit found that Medicare paid $49 million for E/M services that were included in the global surgery fees, but not provided during the global surgery periods in 2007.

The findings further concluded the fees did not reflect the actual number of E/M services provided for 211 of the 300 sampled global surgeries. Specifically, physicians provided fewer E/M services than were included in 165 global surgery fees and provided more E/M services than were included in 46 global surgery fees. For
the remaining 89 global surgeries sampled, either the fees reflected the actual number of E/M services provided during the global periods (24 surgeries) or the surgery was one of multiple surgeries (65 cases).

The OIG recommended CMS adjust the estimated number of E/M services within musculoskeletal global surgery fees to reflect the actual number of E/M services being provided to beneficiaries, or use the results of this audit during the annual update of the physician fee schedule. CMS concurred in part with the recommendations but said they planned to conduct further analysis before proposing any changes in the number of E/M services assigned to the surgeries.

All E/M services related to the surgery during the global period are properly reported using 99024 (the code has no payment associated with it), regardless of location; however, as the OIG found, such services are often reported using a “standard” E/M code, leading to improper payment.

Services (and States) to Watch 

CMS has been busy performing additional analysis, as they promised the OIG in 2011. They have been data mining (reviewing claims) to identify the surgical procedures most frequently reported with either a 10- or 90-day global period. The result is a list of 293 procedures (with global values of either 10 or 90 days) from every “surgical” section in the CPT® codebook.

As of July 1, CMS will audit surgical claims for the 293 identified services to determine if providers are inappropriately reporting E/M services during the global period from all providers in a group of 10 or more sharing a Tax Identification Number in the following states:

  • Florida
  • Kentucky
  • Louisiana
  • Nevada
  • New Jersey
  • North Dakota
  • Ohio
  • Oregon
  • Rhode Island

How to Determine if You Are a Target 

CMS provided additional clarification to help providers determine if they are affected, stating, “Billing practitioners (physicians and non-physician practitioners) are required to report post-operative visits if they:

  • Practice in one of nine states randomly selected by CMS;
  • Practice in a group of 10 or more; and
  • Are part of a practice that provides global services under one of the required procedure codes.

Providers who are not required to report are still encouraged to report post-operative visits. If you are voluntarily reporting, report all visits for all selected procedures.

Reporting is not based on the number of surgeons, but rather the total number of providers in a group. For example, a group of 10 providers (four ophthalmological surgeons and six optometrists) must report, even though most of the providers are not surgeons. CMS believes larger groups have the administrative bandwidth to report, while smaller and single provider practices may not.

Coding the Global Package 

These audits do not create a new requirement: Using 99024 for post-operative visits is a universal coding rule that practices should have been following for years. Code 99024 must be reported for every postoperative service provided after every surgical service that has a 10-day or 90-day global value. That includes codes that are not on the CMS audit target list — even when the procedure-related, post-operative visit occurs in a critical care unit.

Code 99024 does not require the same documentation as standard E/M services. Documentation should describe the patient’s recovery from the surgical procedure and continued treatment plan.

There is a zero-dollar amount associated with 99024 because payment has already been received through the single global surgical payment. If you use billing software that requires a charge, CMS will allow a one-cent charge (.01) to be entered for 99024. If your billing vendor cannot work with this, CMS wants to know. Please email them with vendor issues or concerns at MACRA_Global_Surgery@cms.hhs.gov

Use Modifiers to Denote “Partial” Care 

Surgeons who do not provide the required postoperative visits must bill the original surgery CPT® code with modifier 54 Surgical care only appended.

Compliance Required for All 

On April 25, CMS hosted a presentation titled “Global Surgery: Required Data Reporting for Post-Operative Care Call.” During the Q&A portion of the presentation, CMS was asked twice if an E/M code for a problem unrelated to the post-operative follow-up service can appear on the claim with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. Twice, CMS replied that they do not expect to see an E/M code, other than 99024, to appear on the surgical claim.

There are instances when an E/M code may be used for a problem not related to the surgery, with modifier 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period appended. It’s a good idea to create a separate claim from the surgical service for any unrelated E/M service by the same provider during the global period. Be sure to include an appropriately defined E/M code and an appropriate modifier, linked to the correct diagnosis code for the new problem. If the documentation does not support the separate E/M service, query the provider; you may encounter an audit and may need to provide records.

If you do not have a policy and procedure in place for compliant post-operative coding, now is the time to create one. Be sure to train (and document the training) affected staff including clinical, coding, and billing.

Suggestions 

CMS plans to use audit results as one component of their reconsideration of the dollar value reimbursed for the global period. It’s essential for all surgical providers — even those who do not meet the practice size or who are not in the target states — to accurately report all follow-up surgical services using 99024.

There is clinical concern that termination of the global reimbursement package may result in patients skipping visits to their providers for important post-operative follow up. Unfortunately, this decision could result in poor clinical outcomes, especially for those with multiple medical co-morbidities. If the global surgical bundle is revised, surgeons stand to lose global reimbursement and risk having to report non-compliant poor patient outcomes (a double whammy, especially if the group is participating in an accountable care organization, the Merit-Based Incentive Payment System, or an Advanced Alternate Payment Model).

Educating surgeons, and other providers who perform post-operative follow-up services (nurse practitioners, physician assistants, hospitalists, etc.), as well as coders, is essential. If the practice outsources coding and billing, perform an immediate audit to determine if the vendor is compliant with global surgery requirements, National Correct Coding Initiative edits, and CPT® guidelines. Practices that have coders on staff should also perform an audit of 10 dates of service for surgeons (this is especially important for those in the target states). In addition to coding and billing compliance, auditors are looking for adequate clinical documentation to support provision of the service.


Resources

The following are important links to CMS and OIG reports:

OIG, “Musculoskeletal Global Surgery Fees Often Did Not Reflect the Number of Evaluation

and Management Services Provided,” May 1, 2012: https://oig.hhs.gov/oas/reports/

region5/50900053.asp

CMS, “Global Surgery: Required Data Reporting for Post-Operative Care Call,” April 25, 2017:

www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-

Items/2017-04-25-Global-Surgery.html

2017 Physician Fee Schedule Final Rule:

www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFSFederal-

Regulation-Notices-Items/CMS-1654-f.html

Current list of procedure codes that require post-operative visit reporting: www.cms.gov/

Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Codes-for-

Required-Global-Surgery-Reporting-CY-2017.zip

Global Surgery Fact Sheet: www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf

Global Surgery Data Collection: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/

PhysicianFeeSched/Global-Surgery-Data-Collection-.html

Questions? CMS suggests emailing: MACRA_Global_Surgery@cms.hhs.gov


Barbara Aubry, RN, CPC, CPMA, CHCQM, FABQAURP, is a senior regulatory analyst for 3M Health Information Systems (HIS). As a member of the 3M HIS team that creates and manages medical necessity and other coding data, she works directly with CMS on ICD-10 code assignment for their National Coverage Determinations. Aubry has experience in hospital case management and utilization review. She has managed a utilization management department for an HMO, a team of registered nurse auditors, and was the clinical editor of an e-health patient portal. Aubry’s core focus is regulatory compliance. She is member of the Upper Saddle River, N.J., local chapter.

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