Postoperative Care Reporting Required During Global Surgical Period

Physicians and other professionals on staff in provider-based departments (PBDs), Medicare’s new label for what we previously referred to as hospital outpatient departments, are often inclined to ask this author about providing postoperative wound care for patients who are in a 10-day or 90-day global surgical period. In the article that begins on page 27 of this edition of Today’s Wound Clinic, Donna J. Cartwright, MPA, RHIA, CCS, RAC, FAHIMA, explains that global surgical periods do not apply to PBDs: they can bill for all medically necessary postoperative visits. Cartwright also explains how physicians who perform procedures with 10-day or 90-day global surgical periods can correctly transfer postoperative care to wound care physicians and how both the physician who transferred the care and the physician who assumed the care should report the surgical procedure code with modifiers “-54” and “-55,” respectively.  

In addition, many wound care physicians have many questions about the new postoperative care reporting required during the global surgical period. The Centers for Medicare & Medicaid Services (CMS) plans to eliminate global surgical periods in the future. Therefore, CMS is required to collect data for future use in valuing global surgical services by Section 1848(c)(8)(B) of the Social Security Act. Because the postoperative care reported on claims will determine future payment rates for surgical procedures, physicians in all states may wish to report their postoperative care, even if their practice is not in one of the states required to report postoperative services. This edition of Business Briefs will cover the most frequently asked questions about this new postoperative services reporting requirement and provide answers.

Q: Is it true that all physicians who perform surgical procedures assigned to 10-day and 90-day global surgical periods must report all unpaid postoperative visits on their Medicare claim forms?

A: This question cannot be answered with a simple “yes” or “no.” Here are some facts that physicians should remember about unpaid postoperative visits:

• All physicians are encouraged to report unpaid postoperative visits with Current Procedural Terminology code 99024, postoperative follow-up visit. NOTE: Those who are voluntarily reporting postoperative visits should report for procedures described in this article.  
• Effective July 1, 2017, practices with 10 or more physicians in nine states (Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island) must report their unpaid postoperative services with code 99024 on their Medicare claims.¹

Q: If a practice has five physicians and five non-physician practitioners (NPPs) working within the same tax identification number (TIN), will this count as a practice size of 10?

A: Yes, the practice size is counted based on the number of physicians and NPPs included in a group with the same TIN whose business or financial operations, clinical facilities, records, or personnel are shared by two or more practitioners (not necessarily at the same physical address). Practices with fewer than 10 practitioners do not need to report postoperative visits, even if they are located in one of the nine participating states. 

Q: If another practitioner (different than the physician/NPP who performed the surgical procedure) in the same practice/same TIN furnishes the postoperative care, is that practitioner required to report 99024?

A: Yes, reporting is required when a postoperative visit is furnished by another physician/NPP in the same practice or TIN. However, if another practitioner in the TIN provides care unrelated to the procedure, they should bill using the relevant evaluation and management or procedure code. 

Q: If the physician who performed a surgical procedure with either a 10-day or 90-day global surgical period transfers postoperative care to another physician/NPP, should the practitioner who assumes the postoperative care submit claims with 99024? 

A: Yes, if the physician/NPP who assumes the postoperative care practices in one of the aforementioned nine states and his/her practice includes 10 or more practitioners, the practitioner who assumes postoperative care should submit claims for the postoperative visits.  

Q: If the physician who performs the 10-day or 90-day global surgical procedure practices in two group practices in one of the nine states, but only one of the group practices meets the size threshold, how should the physician submit postoperative visit claims?

A: Because practitioners are required to report postoperative visits if they have relationships with at least one group practice with 10 or more practitioners, practitioners in this situation must report eligible postoperative visits no matter which group practice is associated with the global surgical procedure. 

Q: Can the unpaid postoperative services be performed in all sites of care?

A: Yes, unpaid postoperative visits can occur in all sites of care, including, but not limited to, intensive care units, outpatient clinics, PBDs, skilled nursing facilities, etc. 

Q: When physicians/NPPs in the nine participating states report 99024, will they receive separate Medicare payment for those follow-up visits?

A: No. However, reporting the postoperative services is very important. CMS will study the postoperative claims data to better understand the number of services provided during 10-day and 90-day global surgical periods. CMS will then use its findings to set the work relative value units for surgical codes in all states beginning in 2019. Therefore, physicians/NPPs who perform surgical procedures with 10-day and 90-day global surgical periods in the nine required-reporting states should report all postoperative services to ensure the claims data reflects their own postoperative care patterns. In addition, physicians/NPPs who assume transfer of postoperative care should ensure their claims also reflect their postoperative services.

Q: In the nine participating states, are the physicians/NPPs required to report 99024 for every surgical procedure with a 10-day or 90-day global surgical period?

A: No, CMS selected 293 procedure codes based on the following criteria:

• The surgical procedures were performed by more than 100 practitioners.
• The surgical procedures were performed 10,000 times or had charges exceeding $10 million, based on 2014 claims data.

Ten common wound care-related procedure codes are on the list of 293 procedure codes (with descriptions):

• 11750 - Removal of nail bed
• 12031 - Intermediate wound repair scalp, axillae, trunk, and/or extremities (excluding hands and feet); ≤ 2.5 cm 
• 15100 - Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)
• 15120 - Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)
• 15240 – Full-thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; ≤ 20 sq cm 
• 15260 – Full-thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; ≤ 20 sq cm
• 17000 - Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion 
• 28810 - Amputation, metatarsal, with toe, single
• 28820 - Amputation of toe; metatarsophalangeal joint
• 28825 - Partial amputation of toe; interphalangeal joint

The complete list of 293 procedure codes that require postoperative service reporting can be accessed online.² NOTE: The procedure codes subject to required postoperative reporting will be updated yearly and will be published prior to the beginning of the reporting year.  

Q: If the physician/NPP who performed one of the 293 procedures provides more than one postoperative service per calendar day, should he/she report 99024 for each service?

A: No, only report 99024 once per calendar day per patient, even if the patient is seen more than once per day.

Q: If the physician/NPP who performed one of the 293 procedures provides more than one postoperative service during the global surgical period, can he/she report all of the services on one claim line?

A: Yes, the physician/NPP may list multiple 99024 services on the same claim line as long as the claim includes the applicable range of service dates. 

Q: Does the claim for 99024 need to link to one of the original 293 procedures?

A: No, the postoperative services claim with 99024 does not need to link to the original procedure, but it must include the physician/NPP’s name, the beneficiary, and the date of service.

Q: Are time units or modifiers required on claims with 99024?

A: No, time units and modifiers are not required on 99024 claims.

Q: If the postoperative service is performed via telehealth, should it be reported as 99024?

A: If the patient is located at an eligible telehealth originating site, the relevant postoperative telehealth visit can be reported on the claim with 99024. 

Q: Is postoperative service reporting required for Medicare Advantage and Veterans Affairs patients?

A: No, postoperative service reporting is only required for traditional fee-for-service Medicare patients when Medicare is the primary payer for the procedure with a 10-day or 90-day global surgical period. 

Q: Our billing software system requires a charge for every code on the claim. Will the Medicare Administrative Contractors (MACs) allow physicians/NPPs to place a small charge on the claim with 99024?

A: CMS is working with the MACs to ensure they appropriately process 99024 claims and to ensure that physicians/NPPs can place a 1-cent charge on the claim if their software requires it.

Q: Where can I find CMS’ directions for exact counting of the dates included in 10-day and 90-day global surgical periods?

A: There are numerous explanations for how to count the exact dates included in the 10-day and 90-day global surgical packages. Following are a few resources that this author finds very helpful: 

1. Medicare Claims Processing Manual, Chapter 12, Section 40³
2. CMS’ Global Surgery Fact Sheet⁴  
3. National Government Services’^TM 90-Day Calculator for Major Surgeries⁵
4. Palmetto GBA’s Global Surgery Calculator.⁶ 

Kathleen D. Schaum, MS, is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL; and director, medical products, reimbursement, at Smith & Nephew, Fort Worth, TX. 

References

1. Details for title: CMS-1654-F. CMS. 2017. Accessed online:www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/pfs-federal-regulation-notices-items/cms-1654-f.html

2. List of codes for required Global Surgery Reporting. CMS. 2017. Accessed online: www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/downloads/codes-for-required-global-surgery-reporting-cy-2017.zip

3. Physicians/Nonphysician Practitioners. In: Medicare Claims Processing Manual. Accessed online: www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf

4. Global Surgery Fact Sheet. CMS. 2015. Accessed online: www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/globallsurgery-icn907166.pdf

5. 90-Day Calculator for Major Surgeries. National Government Services. Accessed online: www.ngsmedicare.com/ngs/portal/ngsmedicare/90daygpcal?LOB=Part+B

6. Global Surgery Calculator.  Palmetto GBA. Accessed online: www.palmettogba.com/palmetto/global90.nsf/front?openform