AAFP Calls for Improvements in Valuation of Global Surgical Package Codes

The AAFP is urging CMS to adopt measures that would more fairly and accurately assess the valuation of its global surgical package, saying in a recent letter (4-page PDF; About PDFs) that the agency needs to conduct a more comprehensive review process to "assess whether the valuation of global surgical packages reflects the number and level of postoperative services that are typically furnished."

"The AAFP has long argued that the global surgical packages are inflated in terms of the number and level of postoperative visits assumed to be included and incorporated in the value of the codes in question," said AAFP Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash., in the letter to CMS Acting Administrator Marilyn Tavenner, M.A.

Stream said one of the most important issues involves who is providing the services, and he pointed out that surgeons may employ nurse practitioners (NPs) and physician assistants (PAs) to perform many postoperative visits, leaving surgeons to focus on the surgery alone. According to current Medicare payment rules, postoperative visits handled by NPs or PAs should be paid at a discounted rate, but "these visits are valued at the full physician rate in the global surgical package," said Stream.

The AAFP said it also had identified other "troubling aspects" of the global surgical package. For example, in 2007, CMS revalued the stand-alone evaluation and management (E/M) codes and made an adjustment in the value of all 10-day and 90-day global codes in effect at the time. The adjustments were based on an assumed number and level of postoperative visits included in each code.

As a result, "CMS has de facto valued each of those codes by adding the RVU (relative value unit) of the surgical procedure and all pre- and postoperative E/M services included in the global period rather than by magnitude estimation. Accordingly, if CMS reduces the number of postoperative visits for a given code, the AAFP believes CMS should decrease the work RVUs by the exact amount of the corresponding stand-alone E/M codes," Stream said.

In addition, "the AAFP believes that if CMS reduces the number of postoperative visits for a given code, it should also adjust the practice expense and malpractice RVUs to account for both the decline in the work RVU as well as the elimination of follow-up clinical labor, supplies and equipment with the E/M services in question."

The AAFP also noted that postoperative E/M services occurring in the global surgical period after discharge are assumed to occur in the physician's office. "These visits are valued accordingly in the building blocks that comprise the global surgical service," said Stream.

The AAFP, however, believes that a significant number of these visits occur within the hospital outpatient department. To this end, the AAFP commissioned an examination of the 2010 carrier (physician) and hospital outpatient 5 percent claims files for two codes: 27447, total knee arthroplasty, and 33235, removal of pacemaker electrode. "The analysis showed that of the 13,048 beneficiaries involved with either code 27447 or 33235 in 2010, 918 (7 percent) received a post-discharge follow-up visit in a hospital outpatient setting rather than the physician's office.

"If the assumption is that all post-discharge follow-up visits take place in the surgeon's office, then post-discharge visits taking place in a hospital outpatient setting lead to an overvaluation of the post-discharge E/M services in the global surgical package."

The AAFP called for a more thorough analysis of codes with 10- and 90-day global periods within the larger context of improving the valuation of the global surgical package.

As a final recommendation, the AAFP called on CMS to prioritize global surgical codes with large numbers or questionable levels of postoperative visits, saying that this should be an area of focus in CMS' ongoing efforts to improve the relativity of the Medicare physician fee schedule.