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Research Question

  1. What is the best structure for a set of nonpayment codes that capture the number and level of post-operative visits provided during the global period?

The Centers for Medicare & Medicaid Services (CMS) uses a fee schedule to pay physicians and nonphysician practitioners for their professional services. For many surgeries and other types of procedures, Medicare's payment for the procedure includes post-operative visits delivered during a global period of ten or 90 days anchored on the surgery date. The Medicare Access and CHIP Reauthorization Act of 2015 requires CMS gather the necessary data to appropriately value post-operative care. The law requires CMS to collect data on the "number and level" of visits in the global period from a representative sample of physicians beginning January 1, 2017. Congress suggested, but does not require, that the data be collected through claims.

CMS asked the RAND Corporation to provide recommendations on how to best collect the number and level of post-operative visits through the use of nonpayment claims. To do so, RAND first gathered input from individuals performing surgical procedures on the range of post-operative care provided during the global period. RAND consulted with an expert panel on how to categorize the care into codes that capture the major differences in the breadth and intensity of post-operative care across care settings.

This report provides recommendations for a set of nonpayment codes that combine visit times with the complexity of services, for both inpatient and office-based services. The recommended codes attempt to balance the need for a simple and straightforward system with the demand for a set of codes to capture the granularity and heterogeneity associated with post-operative care delivery.

Key Findings

  • The recommended codes attempt to balance the need for a simple system but one that adequately captures the heterogeneity of post-operative care.
  • The majority of post-operative visits are straightforward; therefore, the key is identifying the smaller number of complex visits.
  • Devising a simple system to facilitate reporting is important to minimize the reporting burden for individuals performing surgical procedures.
  • This report considers the advantages and disadvantages of four approaches for capturing post-operative care through claims: site of care; evaluation and management (E&M) visits; scope of care; and time. E&M is familiar to proceduralists, but the codes are a poor fit for the unique circumstances of post-operative visits and could lead to considerable documentation burden.
  • No single framework (site of care, time, or scope of care) is ideal for capturing post-operative visits. The expert panel was most enthusiastic about a set of codes that used elements of all these frameworks.
  • Nonpayment codes are a poor mechanism to capture practice expenses, which should be captured by other means.

Recommendations

  • We recommend a set of eight codes (six for proceduralists and two for clinical staff) that CMS can use to collect data on post-operative care. The structure of these codes is based on a hybrid approach of using time, scope of care, and setting.
  • In the inpatient setting, visits are divided into typical, complex, and critical care encounters. In the office-based setting, visits are divided into typical versus complex encounters. There are separate codes available for Internet- or phone-based care delivery.
  • The codes are based on ten-minute allotments of time. Incorporating time into the coding framework adds a potentially simple and accurate way to capture much of what makes a visit complex.
  • It will be useful to test these codes with proceduralists to ensure that they are feasible, reliable, and capture the full range of post-operative care.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Overview of Current Payment Policy for Post-Operative Services in the Global Period

  • Chapter Three

    Interviews on Post-Operative Care

  • Chapter Four

    Challenges Identified During Interviews and Expert Panel in Capturing Post-Operative Care via Codes

  • Chapter Five

    Options for Capturing Post-Operative Care

  • Chapter Six

    Recommendations for Capturing Post-Operative Care

  • Chapter Seven

    Summary and Next Steps

This study was funded by the Centers for Medicare & Medicaid Services (CMS) and conducted by RAND Health.

This report is part of the RAND Corporation research report series. RAND reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND reports undergo rigorous peer review to ensure high standards for research quality and objectivity.

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