Modifier Coding Alert

Published on Fri Oct 17, 2014 PDF

Surgeons may benefit from being paid individually for all their visits.

CMS is proposing to eliminate 10-day and 90-day global periods, according to an article in the Federal Register on July 11, 2014 — and the implemented rule is bound to impact your coding.

Read on to learn more about how, if the proposal becomes a rule, it may impact the billing of your physicians E/M services and any surgical procedures.

Welcome Proposal Positives

CMS wants to slowly transition the global periods for all codes to 0-day in an attempt to pay for what is truly being provided without duplication. Services that are medically necessary will be billed separately during pre- and post-operative periods. In CMS’s words, “We are proposing to transform all 10- and 90-day global codes to 0-day global codes beginning in CY 2017,” CMS stated in a fact sheet about the fee schedule proposal.

“Under the mis-valued code initiative, the surgical code would be re-valued to include only those services provided on the day of surgery and to pay separately for visits or services actually furnished after the day of the procedure,” explains Joann Baker, CCS, CPC, CPC-H, owner of Precision Coding and Compliance, LLC in Hackettstown, N.J. “Since the base procedure valuation may change, preparing for the adjustment in revenue and an increase in claim reporting volume may need to be assessed while all visits and services to the patient are completed and billed.”

“The OIG has identified a number of surgical procedures that include more visits in the global period than are being furnished.” Because CMS seems to believe that Medicare is wasting cash by paying doctors for global periods that include visits the doctors don’t actually perform, CMS is proposing to include “all services provided on the day of surgery, and to pay separately for visits and services actually furnished after the day of the procedure …” says CMS in its fact sheet.

In the Federal Register, CMS explains that it believes by moving to only 0-day global codes, there will be positive outcomes, including:

• Increased accuracy of fee schedule payments by more accurately basing the rates on the resources used in the procedures
• Fewer duplicated payments when a patient receives post-op care from a different provider
• Elimination of payment discrepancies between E/M services provided in and outside of global periods 
• Retention of the pre- and post-operative services performed on the same day in the 0-day global
• More accurate data for new payment models and research.

“I do think surgeons will welcome this change because it simplifies office billing procedures,” says Freda Brinson, CPC, CPC-H, CEMC, compliance auditor at St. Joseph’s/Candler Health System in Savannah, Ga. “No longer will surgical dates have to be remembered, counted, and calculated as to when a visit can be billed; no longer will there be the need to stress out over ‘is this really related’ to the procedure.”

You have a few years before the changes take effect, if the proposal goes through. The current 10-day global codes will transition to 0-day in 2017 and the 90-day in 2018. The actual dates will depend on when the analysis is completed for updating the global code values. This proposal isn’t final, but it may be in your best interest to familiarize yourself and your practice with the proposal that may benefit you in the future.

Watch for Downsides, Too

A concern of CMS is that allowing separate payment of E/M visits during post-operative periods will promote unnecessary office visits during post-op periods. Because of this, they will monitor any changes in the use of E/M visits and welcome any payment policy suggestions that will mitigate that kind of change in behavior. 

Another less than optimal side effect may be the possible negative impact to patients. The more complex cases may have more post-op care visits that mean more co-pays. Patients who are concerned about their out-of-pocket may elect to not go for the appropriate follow-up care. The appropriate outcomes will also need to be considered in this proposal.

Read more: To read the fact sheet, visit www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-07-03-1.html. You can review the Federal Register article in its entirety at www.federalregister.gov/articles/2014/07/11/2014-15948/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-clinical-laboratory.