Claims-Based Reporting of Post-Operative Visits for Procedures with 10- or 90-Day Global Periods: Updated Results Using Calendar Year 2019 Data

The Centers for Medicare & Medicaid Services (CMS) currently bundles payment 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 Relative Value Scale 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. The RUC, supported by specialty society committees, also makes recommendations on the total work relative value units (RVUs) to be assigned for a procedure. CMS uses the RUC input, among other data, to assign RVUs to a procedure. RVUs and the number of visits that were used to set valuation 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. The Medicare Access and Children's Health Insurance Plan (CHIP) Reauthorization Act of 2015 mandated CMS to collect data on the number and level of post-operative visits to enable CMS to assess the accuracy of global surgical package valuation. Beginning on 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 (HCPCS) code 99024 (this code has no associated payment).

This study provides results on the reporting of these post-operative visits based on analysis of Medicare fee-for-service claims data for procedures furnished during calendar year 2019. The study describes the share of procedures with any reported post-operative visits and the ratio of the number of reported visits to the number of expected post-operative visits. Prior studies provided results for procedures furnished during (1) the first 12 months of reporting, from July 1, 2017, to June 30, 2018 (Kranz et al., 2019); and (2) January 1, 2018, to December 31, 2018 (Crespin et al., 2021). The substantive results and findings in this study and the prior studies are very similar.

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

Although practitioners were required to report post-operative visits, not all practitioners who furnished procedures may have had post-operative visits, and it is possible that others had post-operative visits but did not report them. We determined the percentage of practitioners who reported one or more post-operative visits during the study period among those who performed any procedures with 10- or 90-day global periods. Across the nine states in which CMS required reporting of post-operative visits, more than 90 percent of hand surgeons, orthopedic surgeons, clinical pathologists, vascular surgeons, neurosurgeons, and ophthalmologists reported one or more post-operative visits. The reporting rate among all practitioners required to report was lower (47.1 percent) because of low rates for nonprocedure-focused physicians, such as primary care practitioners, who perform relatively few procedures.

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

Our analyses focused on clean procedures, which are procedures that do not occur during the global period of any prior procedures with a 10- or 90-day global period on a different date of service. Of the 1.1 million clean procedures with a 10-day global period, 3.5 percent had any post-operative visits reported.¹ 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. CMS uses the RUC survey and other inputs to determine the number of expected post-operative visits, which is used by CMS when they value the procedure.² Overall, the ratio of observed to expected post-operative visits provided was only 0.04 for procedures with 10-day global periods. These results imply that the vast majority of expected post-operative visits for procedures with 10-day global periods are not delivered.

There is variation across specialties in these rates and, therefore, we also calculated the rate of post-operative visits among specialties that perform a higher percentage of 10-day global procedures. Dermatologists performed more procedures with 10-day global periods than any other specialty (47.3 percent of all 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 at least 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 (0.10), and ophthalmology (0.08).

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 469,074 procedures with 90-day global periods, 70.0 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 (74.0 percent) and off-campus hospital outpatient (82.0 percent) settings.⁴ Overall, the ratio of observed to expected post-operative visits provided was 0.38 for procedures with 90-day global periods. Orthopedic surgeons performed the plurality of procedures with 90-day global periods (32.7 percent) 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 (0.53), general surgery (0.43), and urology (0.41). These results imply that although most procedures with 90-day global periods have at least one post-operative visit, the majority of expected post-operative visits are not delivered.

Sensitivity Analyses

We further examined the low rate of post-operative visits through sensitivity analyses to determine potential reasons why so few post-operative visits are reported. First, it is possible that additional post-operative visits are provided but in the form of another separately billed procedure or service. To test for this possibility, we performed a sensitivity analysis using a more expansive definition of post-operative care that included evaluation and management (E&M) services and other procedures performed during the global period. Using this more expansive definition of post-operative care did not have a substantive impact on the patterns we observed.

Underreporting of post-operative visits that do occur might be contributing to the low rate of post-operative visits. Specialty societies have raised the concern that some practitioners were unaware of the reporting requirement. Additionally, some practitioners may be less apt to report post-operative visits because the post-operative visit HCPCS code has no associated payment, even though reporting post-operative visits is required by CMS. However, in a second sensitivity analysis in which we focused only on procedures performed by practitioners who regularly report post-operative visits, we found modestly higher rates of post-operative visits that were still lower than expected.

Our definition of clean procedures, which was used to determine the procedures analyzed in this study, may have not been adequately restrictive, and this might have biased our findings. In a third sensitivity analysis, we compared two different definitions of clean procedures: the primary definition used in this study and an alternative definition that excludes any procedures that overlap with global periods of subsequent procedures. Although the alternative definition reduced the number of included procedures, overall, we did not find substantive differences in our results on the use of post-operative visits under the two definitions.⁵

Summary and Policy Implications

During calendar year 2019, 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 contributing to 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 is 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 that included E&M visits and subsequent procedures performed during global periods, and our results again were largely similar. 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 observed to expected post-operative visits provided.

Given these findings, we recommend that CMS consider one or more of the following 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 should 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. Procedures with little (or negative) work remaining after revaluation could be flagged as potentially misvalued codes and addressed by the RUC.
• 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 procedures with 90-day global periods for which post-operative visit data are available. Procedures with little (or negative) work remaining after revaluation could be flagged as potentially misvalued codes and addressed by the RUC.
• Obtain new recommendations from the RUC: If CMS decided to not revalue global procedures to 0-day global procedures or revalue procedures based on reported post-operative visits, then CMS could address the potential overvaluation of global surgical packages by adding procedures with large discrepancies between expected and observed post-operative visits as potentially misvalued codes. The RUC could then reassess these codes, giving consideration to the results on post-operative visits presented in this study. Visit counts and valuations could be outdated for individual procedures. After receiving the RUC's recommendations, CMS could decide on the final valuation using the survey responses and other inputs.