Why the CMS wants sur­geons to code ev­ery 10 min­utes

Modern Healthcare - - NEWS - By El­iz­a­beth Whit­man

The com­ments flooded in af­ter the CMS pro­posed in July that sur­geons col­lect data on ev­ery 10 min­utes of pe­ri­op­er­a­tive ac­tiv­ity. The Amer­i­can Med­i­cal As­so­ci­a­tion branded the sug­gested re­quire­ment as an “un­due bur­den.” The Amer­i­can As­so­ci­a­tion of Neu­ro­log­i­cal Sur­geons and Congress of Neu­ro­log­i­cal Sur­geons warned the ap­proach “is oner­ous and will re­sult in un­der­re­port­ing of data.”

To stop and code how they spend ev­ery 10 min­utes of their time would be a tall or­der to ask of any­one, much less busy doctors and sur­geons. So why did the CMS pro­pose it?

As the agency ex­plains in its 2017 Medi­care physi­cian fee sched­ule, Medi­care pays for cer­tain ser­vices, such as surgery, as global packages, is­su­ing a sin­gle es­tab­lished pay­ment “for par­tic­u­lar ser­vices that we as­sume to be typ­i­cally fur­nished dur­ing the es­tab­lished global pe­riod,” which can be zero, 10 or 90 days.

Those ser­vices in­clude pre-op­er­a­tive vis­its, in­tra-op­er­a­tive ser­vices, any ser­vices as a re­sult of com­pli­ca­tions fol­low­ing surgery, post-op­er­a­tive vis­its, pain man­age­ment and other ser­vices and mis­cel­la­neous sup­plies.

The prob­lem with this is that the CMS was hav­ing trou­ble with the val­u­a­tion of its 10- and 90-day global packages, which meant it was pay­ing for it­didn’t-ex­actly-know-what ser­vices.

“We do not use ac­tual data on ser­vices fur­nished in or­der to up­date the rates,” the CMS said, a fact it dis­cussed in its 2015 physi­cian fee sched­ule. For 2017 and 2018, it sought to tran­si­tion all 10day and 90-day global codes so they en­com­pass only the day of surgery in or­der “to im­prove the ac­cu­racy of val­u­a­tion and pay­ment” for all of the vis­its, ser­vices and the pro­ce­dure it­self.

MACRA, the Medi­care Ac­cess and CHIP Reau­tho­riza­tion Act of 2015, pro­hib­ited that tran­si­tion. But it also re­quired the CMS to de­velop “a process to gather in­for­ma­tion needed to value sur­gi­cal ser­vices from a rep­re­sen­ta­tive sam­ple of physi­cians.” It needed ob­jec­tive data, with­out which the physi­cian fee sched­ule could have “un­war­ranted pay­ment dis­par­i­ties.”

Ba­si­cally, the CMS lacked ac­cu­rate data. The 2017 pro­posal pointed to a May 2012 re­port from HHS’ Of­fice of In­spec­tor Gen­eral, which found that for 202 of 300 sam­pled car­dio­vas­cu­lar global surg­eries, the num­ber of vis­its on which Medi­care pay­ments were based was not what was ac­tu­ally pro­vided—some­times physi­cians pro­vided more ser­vices, some­times fewer.

To de­ter­mine pre­cisely what ser­vices physi­cians were pro­vid­ing, “all codes are in­tended to be re­ported in 10-minute in­cre- ments,” as ei­ther typ­i­cal, com­plex or crit­i­cal in­pa­tient or out­pa­tient vis­its, the CMS said. Typ­i­cal ac­tiv­i­ties in­cluded tasks such as re­view­ing vi­tals or lab re­sults, ex­am­in­ing a pa­tient, manag­ing med­i­ca­tions and do­ing pa­per­work.

It was af­ter con­sid­er­ing com­ments and in­put from other stake­hold­ers that the CMS pro­posed the new set of codes, which it said would yield “the most ro­bust data upon which to de­ter­mine the most ap­pro­pri­ate way and amounts to pay for ... sur­gi­cal ser­vices.” Physi­cians, sur­geons and their ad­vo­cates dis­agreed.

The AMA, in a let­ter to act­ing CMS Ad­min­is­tra­tor Andy Slavitt, called the codes “il­log­i­cal” and the pro­posed man­date “un­likely to be ef­fec­tive.” Nor was it fea­si­ble fi­nan­cially and lo­gis­ti­cally, the as­so­ci­a­tion said. The es­ti­mated cost of pro­cess­ing new claims from the ad­di­tional cod­ing would ex­ceed $100 mil­lion, the AMA said, and that did not in­clude the cost of hir­ing ex­tra staff to work on IT re­design and help physi­cians.

“Ask­ing physi­cians and their staff to use 10-minute timed in­cre­ments to doc­u­ment all their non-op­er­at­ing room pa­tient care ac­tiv­i­ties is by it­self an in­cred­i­ble bur­den,” es­pe­cially as new re­quire­ments un­der MACRA are set to kick in, the AMA said. “Us­ing 10-minute timed in­cre­ments is not con­sis­tent with the act­ing ad­min­is­tra­tor’s goal to re­duce physi­cians’ ad­min­is­tra­tive bur­den.”

But the aim of this pro­posal is to gather in­for­ma­tion—not nec­es­sar­ily make life eas­ier for physi­cians. The agency rec­og­nized that “some of the data col­lec­tion ac­tiv­ity pro­posed here varies greatly from how the data is cur­rently gath­ered,” the CMS said, adding that it did not know how its ex­pen­di­tures might change as a re­sult of the pro­posed cod­ing. But by collecting data, it said, “we would know far more than we do now about how post-op­er­a­tive care is de­liv­ered and gain in­sight to sup­port ap­pro­pri­ate pack­ag­ing and val­u­a­tion.”

The CMS re­ceived nearly 6,000 com­ments on its pro­posed rule. It will re­spond to those com­ments when it is­sues the fi­nal rule.


From the AMA: “Us­ing 10-minute timed in­cre­ments is not con­sis­tent with the act­ing ad­min­is­tra­tor’s goal to re­duce physi­cians’ ad­min­is­tra­tive bur­den.”

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