Claims-Based Reporting of Post-Operative Visits for Procedures with 10- or 90-Day Global Periods: Updated Results Using Calendar Year 2018 Data

Short abstract

The Centers for Medicare & Medicaid Services (CMS) bundles payments for post-operative care within 10 or 90 days after many surgical procedures. Congress mandated that CMS collect data on the number and level of post-operative visits to enable CMS to assess the accuracy of global surgical package valuation. The authors of this article summarize patterns of post-operative visits for procedures furnished during calendar year 2018.

Abstract

Medicare payments for most surgical procedures cover both procedures and post-operative visits occurring within a global period of either ten or 90 days following procedures. There have been concerns that fewer post-operative visits are provided than the number of post-operative visits considered when the procedure was valued. To help inform accurate valuation of procedures with global periods, the Centers for Medicare & Medicaid Services (CMS) required select practitioners to report on post-operative visits after select procedures with 10- or 90-day global periods. The authors of this article summarize patterns of post-operative visits for procedures furnished during calendar year 2018, building on prior research that analyzed data for procedures with July 1, 2017, through June 30, 2018, service dates.

During calendar year 2018, 96.5 percent of procedures with 10-day global periods did not have an associated post-operative visit. Approximately two-thirds of procedures with 90-day global periods had an associated post-operative visit; however, the ratio of observed to expected post-operative visits provided for 90-day global period procedures was only 0.38.

Underreporting of post-operative visits might be driving these low rates. However, in sensitivity analyses limited to practitioners who were actively reporting their post-operative visits, post-operative patterns were largely similar to the main analysis. Collectively, these findings suggest that a large share of expected post-operative visits are not delivered, and that underreporting is unlikely to fully explain the low ratio of expected post-operative visits provided.

The Centers for Medicare & Medicaid Services (CMS) currently bundles payments for post-operative care within 10 or 90 days after most surgical procedures. To inform the valuation of this bundled payment by the American Medical Association's Relative Value Scale (RVS) Update Committee (RUC), surgeons are surveyed on the typical number of post-operative visits provided after a given procedure during the 10- or 90-day global period. CMS uses the survey as one of several inputs to set the number of visits that CMS assumes when valuing procedures and which are reported in the Medicare Physician Fee Schedule. Historically, CMS had not collected data on how many post-operative visits are actually performed in the surgical global periods and how this number compares with the number of visits considered during the valuation process. To enable CMS to assess the accuracy of global surgical package valuation, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) mandated that CMS collect data on the number and level of post-operative visits. Beginning July 1, 2017, CMS required select practitioners in nine states (Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island) to report on post-operative visits after select procedures with 10- or 90-day global periods. These post-operative visits were reported using Healthcare Common Procedure Coding System code 99024 (this code had no associated payment). This study provides results on the reporting of these post-operative visits based on analysis of fee-for-service Medicare claims data for procedures furnished during calendar year 2018. The study describes the share of procedures with any post-operative visits and the ratio of observed-to-expected post-operative visits provided.

A prior study provided results for procedures furnished during the first 12 months of reporting from July 1, 2017, to June 30, 2018 (Kranz et al., 2019). The main results in this study and the prior study are largely similar, as described in the following sections. This is to be expected, to some extent, because the source data for the two studies overlap by six months (the current study analyzes data for procedures with service dates in calendar year 2018, compared with the prior study that analyzed data for procedures with July 1, 2017, through June 30, 2018, service dates).

In Procedure-Focused Specialties, Most Practitioners Are Reporting Post-Operative Visits

Across the nine states in which CMS required reporting of post-operative visits, more than 90 percent of hand surgeons, orthopedic surgeons, vascular surgeons, ophthalmologists, and clinical pathologists reported one or more post-operative visits.¹ Overall reporting rates were lower; 46 percent of practitioners who were expected to report did so. This is, in part, because of the low reporting rate of primary care practitioners. More than 19,000 practitioners working in more than 1,800 practices reported one or more post-operative visits during the year.

A Small Percentage of Procedures with 10-Day Global Periods Have Any Post-Operative Visits

When examining clean procedures that do not occur during the global period of another procedure with a 10- or 90-day global period and its linked post-operative visits, we found that 3.5 percent of the 1,043,039 procedures with 10-day global periods had any post-operative visits reported. We then compared the number of post-operative visits for each procedure reported in the claims data with the number of expected post-operative visits for each procedure.² Overall, the ratio of observed-to-expected post-operative visits provided was 0.04 for procedures with 10-day global periods. Dermatologists performed 48.0 percent of procedures with 10-day global periods. Among 10-day procedures performed by dermatologists, the observed-to-expected ratio was 0.03. Among other specialties performing 10,000 procedures with 10-day global periods, the highest ratios of observed-to-expected post-operative visits were observed for general surgery (0.20), otolaryngology (0.11), and ophthalmology (0.08).

In a sensitivity analysis to capture post-operative care provided in the context of other clinical encounters, we used a more expansive definition of post-operative care, which, beyond post-operative visits, also included other evaluation and management (E&M) services and other procedures. Using this more expansive definition of post-operative care did not have a substantive impact on the patterns we observe. In a second sensitivity analysis, we identified a set of practitioners who appeared to be actively engaged in reporting post-operative care. Among this subset of practitioners, we found modestly higher rates of post-operative visits that were still lower than expected.

Most Procedures with a 90-Day Global Period Have at Least One Post-Operative Visit, but Fewer Total Visits Are Provided as Compared with What Is Expected

Of the 477,085 procedures with 90-day global periods, 69.1 percent had one or more associated post-operative visits reported.³ Among procedures with 90-day global periods, reporting of post-operative visits was greatest among procedures furnished in inpatient (73.1 percent) and off-campus hospital outpatient settings (81.6 percent). We then compared the number of post-operative visits for each procedure reported in the claims data with the number of expected post-operative visits for each procedure. Overall, the ratio of observed-to-expected post-operative visits provided was 0.38 for procedures with 90-day global periods. Orthopedic surgeons performed 31.9 percent of procedures with 90-day global periods and had an observed-to-expected ratio of 0.32. Among other specialties performing more than 10,000 procedures with 90-day global periods, the highest ratios were observed for ophthalmology (0.54), and urology (0.42),⁴ and general surgery (0.40). In sensitivity analyses, these ratios increased only modestly when we used a more expansive definition of post-operative care or focused on the subset of practitioners actively reporting post-operative visits.

Sensitivity Analyses

In a sensitivity analysis to capture post-operative care provided in the context of other clinical encounters, we used a more expansive definition of post-operative care, which beyond post-operative visits also included other evaluation and management (E&M) services and other procedures. Using this more expansive definition of post-operative care did not have a substantive impact on the patterns we observe. In a second sensitivity analysis, we identified a set of practitioners who appeared to be actively engaged in reporting post-operative care. Among this subset of practitioners, we found modestly higher rates of post-operative visits that were still lower than expected.

Summary and Policy Implications

During calendar year 2018, we found that 96.5 percent of procedures with 10-day global periods did not have an associated post-operative visit. Approximately two-thirds of procedures with 90-day global periods had an associated post-operative visit; however, the ratio of observed-to-expected post-operative visits provided for 90-day global period procedures was only 0.38.

Underreporting of post-operative visits might be driving these low rates. However, in sensitivity analyses limited to practitioners who were actively reporting their post-operative visits, post-operative patterns were largely similar to our main analysis. Another potential way to explain the low rates of post-operative visits was that post-operative care is occurring during E&M visits or included with appointments for subsequent procedures. In a second sensitivity analysis, we used a more expansive definition of post-operative care and our results again were largely similar. Collectively, these findings suggest that a large share of expected post-operative visits is not delivered, and that underreporting is unlikely to fully explain the low ratio of expected post-operative visits provided.

Given these findings, CMS could consider one or more of these proposed policy options:

• Revalue 10-day global procedures as 0-day global procedures: Although the share of post-operative visits reported was low for all procedures, it was particularly low for procedures with 10-day global periods. CMS could consider revaluing some or all procedures with 10-day global periods to 0-day global periods. Practitioners who furnish post-operative visits for such procedures would be paid separately by billing E&M codes when needed.

• Obtain new recommendations from the RUC: CMS could address the potential overvaluation of global surgical packages by asking the RUC to revalue select or all global procedures. The RUC currently surveys physicians to obtain expected counts of post-operative visits, which are used to inform CMS's valuation of the procedures. The RUC could use the data in this study to inform those revaluations or conduct new surveys on the typical number of post-operative visits. These survey responses are used by the RUC as part of the process to provide CMS with valuation recommendations. CMS could decide on the final valuation using the new survey responses and other inputs.

• Revalue 90-day global procedures using the number of post-operative visits reported: Using the information on post-operative visits collected in the nine states, CMS could consider revaluing all procedures with 90-day global periods using the number of post-operative visits reported in the claims data or from other sources.