Advocacy in Action - What’s in the Proposal: Global Surgical Codes

Carter L. Alleman, J.D.

Last month, I discussed the administrative rulemaking process with the development of Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA). I decided to return to the topic again this month to discuss the proposed global surgical code rulemaking in the CY 2017 Physician Fee Schedule. The rulemaking is of great concern to the surgical world as it will change how surgeons are paid.

Centers for Medicare & Medicaid Services (CMS) released the Annual Physician Fee Schedule rule proposal. In the rule proposal, CMS outlines how it will collect the data on global surgical codes it wants to revalue. The proposal is outlined below.

A brief history on the global surgical code issue. CMS decided that the 10 and 90 day global surgical codes are overvalued, mainly because of post-operative care that is built within these codes. Instead of using the established revaluing process, CMS wanted to do a wholesale zeroing of the globals and then reissue the payments through bundling. The problem with this approach is that there are services included in the globals that do not have known values such as surgical materials. Also each patient treated under these codes are not the same, whereby one may need less post op care while another needs more which resulted in the globals being a balance.

CMS’ belief is that through revaluation it can save money and provide better care by revaluing these codes. The surgical associations went to Congress to stop CMS from doing the revaluation. As part of MACRA, Congress instructed CMS to conduct a study to gather the data for the codes by surveying a representative body of surgeons. After the survey is completed and the data is reviewed, then at that time can CMS being revaluing the codes if necessary.

CMS proposal is a three-part rule. The first part would be to require all claims data used for global surgical codes. CMS is looking to have surgeons use G-codes. In their eyes, this would allow them to judge the severity and number of post-operative care visits. The reporting of this data would be mandatory. The second part would be a survey conducted by the RAND Corp to approximately 5,000 surgeons this would be an in-depth survey regarding how surgeries are being performed and what is the normal use load. The final will be an on the ground observation of selected surgeons across the nation. A 5% penalty fee may be administered to surgeons who do not report, however CMS states that the penalty will not be used.

The ACOS participated in a conference call with other surgical associations to discuss the proposed. The first issue raised was the administrative burden. It was noted that some surgical electronic health record (EHR) systems are not set up for G-codes. Also, it was noted that G-codes delay the reimbursement for treatment. The discussion also highlighted that the use of 9 G-codes to note the length and severity of the visit will create confusion.

The American College of Surgeons and their supporters on the Hill are passing around a “Dear Colleagues” letter asking for support to tell CMS that it has overstepped its bounds with requiring ALL surgeons to report and ignoring Congressional intent of a representative sample. No legislative action will occur till after September when Congress comes back for its lame duck session.

At the American Osteopathic Association (AOA) House of Delegates meeting, the ACOS had a chance to speak briefly with members of the AOA Relative Value Scale Update Committee (RUC) delegation. The members encouraged the ACOS to submit to them comments that can be shared at an upcoming RUC meeting on our position. The ACOS is actively drafting this comments. Another insight was given regarding the scope of the mandatory surveying. The reason for the mandatory surveying is that CMS wants to have all the data in order to find the average to base the global surgical codes. It feels that after the savings it found while doing the Comprehensive Care for Joint Replacement Model that there are other globals that are misvalued and ripe to produce savings. This is more of a gut feeling but with the survey data CMS can then prove its point.

The ACOS will be working with its Government Affairs Committee to submit a comment letter to CMS on this issue. The ACOS also encourages all members to contact their Members of Congress who are in district for their 7-week recess and ask them to sign-on to the “Dear Colleagues” letter. If you have any comments or opinions that you would like to be included, please do not hesitate to contact the ACOS.