Surgeons to CMS: Don't Make Us Code Every 10 Minutes of Work

September 08, 2016

Organized medicine is staging a global revolt that has nothing to do with politics or coups.

Instead, it's a revolt against a Medicare proposal to have surgeons use new billing codes to track their work in 10-minute increments during global surgical "packages" that span 10 days and 90 days. Medicare pays a lump sum for these packages, which include preoperative and postoperative care as well as the procedure itself. There are about 4200 procedures that Medicare reimburses this way.

In a survey of some 7000 surgeons conducted by 23 medical societies, 37% estimated that compliance would cost them between $25,000 and $100,000 in terms of modifying electronic health record (EHR) and billing systems, hiring scribes to document all 10-minute segments of work during a global period, seeing fewer patients, and other changes. Another 15% put the anticipated cost at over $100,000.

"More administrative nightmares," the survey quoted one unnamed orthopaedic surgeon as saying. "How much more does CMS expect us to take?"

The plan to put global packages on a stopwatch appears in the proposed Medicare Part B fee schedule for 2017 from the Centers for Medicare & Medicaid Services (CMS). Groups such as the American College of Surgeons (ACS), the American Association of Orthopaedic Surgeons, the American Association of Neurological Surgeons (AANS), the Congress of Neurological Surgeons (CNS), and the American Medical Association have filed protests with CMS. They're worried about not only burdensome reporting requirements but also the possible elimination of global surgical packages by CMS someday in its quest for cost savings.

Here's the back story. In 2014, CMS proposed a fee schedule for 2015 that would phase out 10-day global packages in 2017 and 90-day packages in 2018. They would be replaced by a 0-day package, meaning that CMS would bundle all preoperative and postoperative care on the day of the surgery together with the operation itself and pay a lump sum for it. However, surgeons would bill Medicare on a piecemeal basis for preoperative care in the days beforehand and for postoperative care in the days afterward.

CMS pointed to studies showing that most surgeons don't perform as many postoperative services as the global period call for. For example, the payment for a 90-day global period may assume 10 postoperative office visits, but the surgeon may see the patient only 6 times. For that surgeon, the global payment is an overpayment.

Penalty for Failure to Report New Codes Remains an Option

The Medicare Access and CHIP Reauthorization Act (MACRA) blocked the implementation of this particular CMS proposal but seemingly left the door open for future action. The law directed CMS to begin collecting information on the value of global-package services from a representative sample of physicians no later than January 1, 2017. That information, according to the law, should include the number and level of patient visits within the global period.

The proposed fee schedule for 2017 calls for surveying a representative sample of surgeons about office visits included in global packages as well as a more in-depth, observational study of preoperative and postoperative care performed at a small number of sites, including some accountable care organizations. However, what has set off the current controversy is the plan for all surgeons to indicate on Medicare claims the number and level of preoperative and postoperative visits furnished in every global package with eight new "G" codes. Each G code describes 10 minutes' worth of care.

Table. Proposed Global Service Codes

GXXX1 Inpatient visit, typical
GXXX2 Inpatient visit, complex
GXXX3 Inpatient visit, critical illness
GXXX4 Office or other outpatient visit, clinical staff, typical
GXXX5 Office or other outpatient visit, typical
GXXX6 Office or other outpatient visit, complex
GXXX7 Patient interactions via phone or Internet by physician/nonphysician practitioner
GXXX8 Patient interactions via phone or Internet by clinical staff

Source: CMS


The new codes are for reporting purposes only. Although physicians will submit them on Medicare claims, they will not receive separate payments for these G codes as they do for others because the services in question are covered by the global payment.

CMS said that to gain an accurate picture of global services, it's necessary to survey all physicians who perform them, not just some. Reporting the new G codes on Medicare claims would be mandatory, said CMS, noting that requests for physician practices to submit expense data voluntarily often go ignored. MACRA authorizes CMS to withhold up to 5% of Medicare reimbursement from physicians who fail to report the new G codes for global services, but the agency said it would not implement this penalty unless compliance proves to be "not acceptable."

"Soul-Crushing Intervention"

Many medical societies complain that the CMS proposal for all physicians to report the new G codes for all global packages oversteps the MACRA mandate to survey a representative sample of physicians. That's just the opening salvo of criticism. The ACS, for example, said that the plan will yield an incomplete and inaccurate picture of global services.

For one thing, the G codes don't jibe with how surgeons work, the ACS said in a letter to CMS. Patient care goes beyond face-to-face visits. Surgeons meet with their clinical teams, for example, to discuss several cases at a time in follow-up to a previous patient visit or in preparation for the next. These group meetings don't lend themselves to neat, 10-minute increments of time per patient. Nor do off-and-on dealings with individual patients. A surgeon might be reviewing a postoperative patient's pathology report with him or her when a nurse calls about problems about two other postoperative patients, according to the ACS.

"The surgeon would have to stop the timer on the first patient's pathology review, start and stop timers on the second and third patients when answering the phone and then restart the timer on the first patient in the office," said the ACS, which noted that the new codes have never been tested for their usefulness. "This often happens many times in a day."

The ACS also faulted the new G codes for typical visits for not capturing the full range of work a surgeon may perform. Changing wound dressings is listed as an activity in a typical visit, yet wound management can be straightforward or extremely complex. The society compared managing small incisions after an uncomplicated laparoscopic cholecystectomy with tending to a nursing home patient who has a large open wound after surgery for perforated colonic diverticulitis — and who has dementia.

Besides highlighting other shortcomings of the new G codes, the ACS and other medical societies said that coding for 10-minute increments of work would impose a Herculean task on physicians and distract them from patient care. In their joint letter to CMS, the AANS and CNS calculated that during the 90-day global period for a lumbar spinal fusion for a traumatic fracture, a neurosurgeon might easily report a total of 32 G codes on Medicare claims for postoperative care, including 2 G codes for the final patient visit on day 90. As of now, a neurosurgeon need not submit a Medicare bill for his or her inpatient rounding, discussions with other physicians, or office visits during that global period.

"People trying to honestly track every 10 minutes of time will quickly burn out," the AANS and CNS quoted one neurosurgeon as saying in their letter to CMS. "This type of soul-crushing intervention will simply encourage physicians to compete for non-government payers, and restrict access (or lose it altogether) for Medicare and Medicaid patients."

Medical societies protesting the CMS proposal have laid out compromise positions that run along similar lines. To fulfil the MACRA mandate to evaluate global package services, they say, the agency could conduct a survey limited to a subset of high-volume procedures paid on a global basis, not all 4200 of them. CMS also could limit the survey to a representative sample of surgeons — again, not all of them. And the agency could ask surgeons to report postoperative visits, the focus of the survey, on Medicare claims with the existing CPT billing code of 99024 rather than untested G codes. The 99024 code, intended for postoperative visits in a global package, dispenses with any timekeeping. CMS has floated that alternative as well.

After mulling over what it's heard from organized medicine and other stakeholders, CMS is expected to issue the final version of its 2017 Medicare Part B fee schedule this fall.

Follow Robert Lowes on Twitter @LowesRobert


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