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Summary of Claims-Based Reporting of Post-Operative Visits for Procedures with 10- or 90-Day Global Periods

Core Content

This report examines the patterns of post-operative visit reporting for procedures with 10- or 90-day global periods under the Centers for Medicare and Medicaid Services (CMS) bundled payment system. The study analyzes data from the first year of reporting, which began on July 1, 2017, and ended on June 30, 2018, focusing on the use of HCPCS code 99024 for reporting post-operative visits. The findings aim to inform the accuracy of global surgical package valuation by the American Medical Association's RVS Update Committee (RUC).

Main Findings

1. Reporting Rates by Specialty

• Only 46% of expected reporters actually reported post-operative visits.
• More than 90% of hand surgeons, orthopedic surgeons, vascular surgeons, ophthalmologists, neurosurgeons, clinical pathologists, and urologists reported post-operative visits.
• Roughly three-quarters of post-operative visits occurred in office settings.

2. Share of Procedures with Post-Operative Visits

• 3.7% of procedures with 10-day global periods had any post-operative visits reported.
• 70.9% of procedures with 90-day global periods had one or more post-operative visits reported.
• Inpatient and off-campus hospital outpatient settings had the highest rates of post-operative visit reporting (74.5% and 78.5%, respectively).

3. Observed to Expected Ratio

• The observed to expected ratio of post-operative visits was 0.04 for 10-day global period procedures and 0.39 for 90-day global period procedures.
• Dermatologists had the lowest observed to expected ratio (0.04) for 10-day procedures.
• For 90-day procedures, the highest observed to expected ratios were seen in ophthalmology (0.57), general surgery (0.41), and hand surgery (0.39).

4. Sensitivity Analyses

• Using a more expansive definition of post-operative care (including E&M services and other procedures) did not significantly change the observed patterns.
• A subset of active reporters showed slightly higher reporting rates, but still lower than expected.

Key Information

Reporting Requirement

• CMS required select practitioners in nine states to report post-operative visits using HCPCS code 99024.
• The nine states were randomly selected based on size and region.
• Reporting was required for 299 common procedure codes with 10- or 90-day global periods, performed by more than 100 practitioners and more than 10,000 times or with allowed charges over $10 million.

Data Sources

• The data came from FFS Medicare final action professional claims in the CMS Integrated Data Repository (IDR).
• The study excluded procedures with unusual post-operative care patterns using specific modifiers.
• Ambulatory Surgery Center (ASC) facility records were excluded, but claims from practitioners working in ASCs were retained.

Methods

• Linking procedures and visits was done using dates of service, beneficiary ID, and global period length.
• Practice size was calculated by summing the number of practitioners under a given TIN.
• Sensitivity analyses were conducted to address potential underreporting and to test the impact of alternative definitions of post-operative care.

Policy Implications

• Underreporting may be a factor in the low observed to expected ratios, but the patterns remained largely consistent even when focusing on active reporters.
• Low reporting rates for 10-day procedures suggest that CMS may need to consider revaluing or changing the global period for these procedures.
• Potential policy options include:
  • Revaluating procedure codes based on actual post-operative visit data.
  • Converting 10-day global procedures to 0-day to allow separate billing for post-operative visits.
  • Obtaining new recommendations from the RUC using the collected data.

Limitations

• TIN-based practice identification may not accurately reflect CMS's definition of a practice.
• The definition of a practice used in the study may understate the number of expected reporters.
• Data collection was limited to a subset of states and procedures, which may affect the generalizability of the findings.

Conclusion

The report highlights significant discrepancies between the expected and observed number of post-operative visits for procedures with global periods. These findings suggest that current valuation methods may not accurately reflect real-world clinical practices, prompting a need for policy changes or revaluations to ensure fair payment for surgical procedures.