Published 6/1/2017
Margaret M. Maley, BSN, MS; the AAOS Coding Coverage and Reimbursement Committee

Medicare Sharpens Focus on the Global Surgical Package

The Centers for Medicare & Medicaid Services (CMS) has expressed concern that services with 10- and 90-day postoperative periods are not valued accurately, and follow-up visits included in the value of the global services are not consistently being performed. Consequently, as required by the Medicare Access and CHIP Reauthorization Act (MACRA), CMS mandated the reporting of postoperative visits for 293 Current Procedural Terminology (CPT) codes for providers in the following nine states beginning July 1, 2017:

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

These postoperative visits should be reported with CPT code 99024, which the CPT book uses to describe "a 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."

In the nine states previously listed, 99024 reporting will be required on Medicare fee-for-service claims in groups with 10 or more practitioners. Physician or qualified nonphysician practitioners (eg, nurse practitioner, physician assistant) who furnish services to patients are included when enumerating a group's practitioners. These practitioners do not need to share the same physical address to be considered part of the same practice, but may share a tax identification number. Physicians in teaching hospitals are included in this mandatory reporting requirement.

The place of service designations where reporting must occur include, but are not limited to, inpatient hospital, outpatient hospital, ambulatory surgical center (ASC), intensive care unit, critical care unit, skilled nursing facility, or a physician's office. This means that inpatient postoperative hospital rounding visits related to the surgical procedure would be reported, a dramatic departure from current practice, wherein many of these encounters are not tracked at all.

CMS identified the surgical codes subject to global visit reporting using 2014 claims data for services that are "reported annually by more than 100 practitioners and are reported more than 10,000 times or have allowed charges more than $10 million annually." Although specific criteria are not described in CPT, the encounter documentation should capture all the work and services in the postoperative visit. It is important that all postoperative visits are captured and documented using the follow-up visit guidelines, as CMS could evaluate and extrapolate the data, determine that the services are overvalued, and reduce the relative value units (RVUs) of the surgical codes accordingly.

CMS published the list of the 293 targeted codes in January 2017. Surgeons and their business offices should review the list and identify the surgical codes used in their practices.

Of the 293 codes selected for reporting, 68 are from the musculoskeletal chapter and an additional 30+ codes are from the nervous system and integumentary chapters. The codes for procedures commonly used in orthopaedics (from the musculoskeletal and nervous system chapters) include arthrodeses, fracture care, arthroplasties, arthroscopies, carpal tunnel releases, and laminectomies. (see Table 1). Like most regulations involving CPT and diagnosis codes, orthopaedics has the largest percentage of codes on the list. Orthopaedic groups of qualifying size that are located in one of the nine selected states should review the entire list of codes. Although there are still questions about the reporting of these postoperative visits, CMS provided the following specific direction during the national provider conference call on global surgery held on April 25, 2017:

  • Physician and nonphysician practitioners, including those who work under physician supervision, are required to report postoperative visits beginning the day after the procedure regardless of the place of service.
  • Group size is determined at the level of tax identification number. For example, in a multispecialty setting, even if there are fewer than 10 providers in the surgical division, reporting is still required in the designated states if the total practice size is greater than 10 providers.
  • Practices may also report postoperative encounters for codes not on the list. Administratively, staff do not need to pick and choose which postoperative encounters are released for billing, but it would also result in a higher number of 99024 codes appearing on Medicare claim remittances.
  • Providers in other states may also report 99024 encounters.
  • Providers are encouraged to begin submitting 99024 encounters prior to July 1 to test their practice management and clearinghouse systems.
  • Visits are to be reported on claims using code 99024 with the correct date of service.¬†
  • Multiple 99024 codes can be reported on a single line of the claim form by changing the number in the units box. The correct range of service dates should be listed.
  • CMS states that the "usual Medicare billing requirements to demonstrate that visits were provided and code was correctly used" should be followed. The proper documentation of these visits is important because it is currently unclear if Medicare will gain all the information about the "level or intensity" of the service and additional resources used (such as dressings and suture kits) from additional surveys, American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) data, or record review.
  • Multiple postoperative visits to the same patient on the same date of service are reported with a single 99024 code. If the services are unrelated to the surgery (E&M services with a modifier 24 indicate that they are "unrelated," while procedural services with the modifier 79 indicate the procedure is "unrelated"), they should be reported according to normal billing rules.

Claims with a $0 charge are often rejected by some claims-processing software.

"It has been a challenge for our practices to keep up with reporting these postoperative visits for this exact reason," said Cheyenne Brinson, a practice management expert with KarenZupko & Associates.

Adding a one-cent fee to force the claim through is an administrative burden, as is the removal of this nominal charge after claims processing. We encourage groups to have software programmed to automatically write off the one cent charge as an adjustment to bring the balance to zero."

As of the April national provider conference call, CMS indicated that they are working with contractors to ensure that claims will be processed or that a $0.01 charge could be added to the claim if the provider's software requires it.

Practices should keep in mind that, if they are required to report 99024 in the postoperative period, even inpatient visits must be reported. They should be sure that documentation adequately captures the service, and should report all services. Incomplete collection of postoperative data could negatively affect surgical code valuation.

Margaret M. Maley, BSN, MS is a senior consultant specializing in orthopaedic coding and reimbursement with KarenZupko&Associates.

Additional Information:
Complete list of 293 surgical codes for which CMS has mandated the reporting of postoperative visits for nine states beginning July 1, 2017
Transcript and audio of the national provider call, "Global Surgery: Required Data Reporting for Post-Operative Care Call  April 25, 2017," on the MLN connects website