EVALUATION AND MANAGEMENT (E/M) CODES/10-AND-90 DAY GLOBAL SURGICAL CODES
In the 2021 Medicare Physician Fee Schedule (MPFS) final rule, the Centers for Medicare and Medicaid Services (CMS) increased reimbursement for standalone E/M services but did not make corresponding increases to the value of E/M post-operative services in 10- and 90-day global surgery codes.
Currently, Medicare pays surgeons and other specialists a single fee (global payment) when they perform major or minor surgery, such as cataract surgery. This single fee covers the costs of the surgery plus related care prior to surgery and follow-up care within a 10- or 90-day post-operative timeframe. CMS establishes these global payments to include payment for both the surgical procedure and the post-operative/follow-up visits-a type of E&M visit. Post-operative visits include services such as post-surgical pain management; local incision care; removal of sutures and staples, drains and casts; and more.
ASCRS is partnering with the American College of Surgeons and the Surgical Coalition to advocate that the E/M standalone visit increases be applied to the E/M post-op visits included in the 10- and 90-day global surgery codes. Additionally, ASCRS has joined the Surgical Care Coalition in a new advocacy campaign highlighting the importance of surgeons in our healthcare system. The campaign is part of a multi-faceted approach demonstrating the value of surgery. The goal of the campaign is to protect patient access to surgical care by preventing significant Medicare physician payment cuts for CY2022.
Congress should direct the Centers for Medicare & Medicaid Services (CMS) to adjust the evaluation and management (E/M) post-operative visits included in 10-day and 90-day global surgical codes to reflect the updated office/outpatient E/M code payment increases that were implemented on January 1, 2021. It is critical that CMS increase the E/M portion of the global codes because to do otherwise will:
- Disrupt the relativity in the fee schedule. Changing the values for some E/M services, but not for others, disrupts the relativity mandated by Congress as part of the Omnibus Budget Reconciliation Act (OBRA) of 1989 (P.L. 101-239), which was implemented in 1992 and refined over the past 27 years. In the past, every time the payments for new and established office visits were increased, CMS also adjusted the global surgery bundled payments to account for the increased values for the E/M portion of these codes.
- Create specialty differentials. The Medicare statute specifically prohibits CMS from paying physicians differently for the same work, and the “Secretary may not vary the . . . number of relative value units for a physicians’ service based on whether the physician furnishing the service is a specialist or based on the type of specialty of the physician.” Failing to adjust the global code payment is equivalent to paying some physicians less for providing the same E/M services.
- Conflicts with section 523(a) of MACRA. Through the Medicare Access and CHIP Reauthorization Act (MACRA), Congress required CMS to collect data on global codes. Notwithstanding this ongoing project, nothing in Section 523(a) of MACRA precludes CMS from making these equity adjustments to the global codes in the meantime.
- Process exists to re-evaluate “misvalued” codes. If CMS feels that specific global codes are “misvalued,” the agency should request the AMA’s RUC to review these codes to ensure the global payments accurately reflect the actual services being provided to patients.
ASCRS is working with the surgical community advocating that Congress should direct the CMS to adjust the values of the E/M post-operative visits included in 10-day and 90-day global surgical codes to reflect the updated office/outpatient E/M code payment increases that were implemented on January 1, 2021.
How it Impacts You
Because of the budget neutrality of the fee schedule and the high volume of E/M services billed, the overall increase to the standalone E/M codes has a significant redistributive effect, transferring value from procedure-based specialties to primary care. Based on an analysis conducted by the surgical coalition, ophthalmology is among the most negatively impacted specialties from the policies in the final rule. However, if the post-operative E/M visits are increased in the global codes, ophthalmology would see a 4.74% increase in Medicare payments for 2022.