Failing to report on global period codes this year could lead to payment changes that would cost dermatologists a collective $1 billion.

Presently, surgical procedures and follow-up visits are paid by Medicare as a single bundled payment, with the expectation that the follow-ups will occur within a 10- or 90-day period. CMS tried to eliminate these global period codes in 2014, but Congress stepped in and, as part of passage of the MACRA reform law, required the agency to study the effects of such a shift.

The Medicare physician fee schedule for 2017 requires groups of 10 or more providers in nine states to begin reporting after July 1 on when exactly the procedure follow-up visits are occurring, though CMS is encouraging reporting for the full year. The test states are Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island.

Whether this test will demonstrate clearly just how much dermatologists rely on global periods to cover the services they render remains to be seen.

The required reporting is resource intensive and onerous, Murad Alam, MD, of Northwestern University, Chicago, said in an interview. “No one’s really going to report them.”

“I think its definitely not going to be successful in capturing the data needed to keep the global period,” he said, adding that dermatologists alone could lose more than $1 billion if global periods were eliminated.

CMS wants to understand when follow-up visits happen. It is asking providers in those nine states to submit CPT code 99024 for each follow-up visit related to a surgical procedure and will be looking for the follow-up visit code linked to procedures reported by 100 or more physicians, that have 10,000 or more occurrences, or that have allowed charges of more than $10 million annually. The extent to which the CPT code is reported could impact whether global periods are maintained.

“The way [the test] was developed was – I would hate to think by intent but certainly by design even if not intent – it’s going to necessarily result in significant underreporting, which will inevitably result in the conclusion that … the global periods will go away,” Dr. Alam said.

One possible solution would be to simply subtract the value of the follow-up visits from the global period payments and pay them separately, but Dr. Alam said that paying them separately would not necessarily provide equal levels of payment.

“If you subtract the value of the level two follow-up visits from that code, you don’t get where you need to be,” he said. “In some cases, you actually end up with negative values for codes.”

Plus, it would take a while to properly value the codes for the follow-up visits following a surgery, particularly for those following surgical procedures in dermatology, as they tend to be resource intensive, he said.

And that does not factor into the equation the additional administrative burden of filing claims for each individual follow-up visit.

The only way this issue might be resolved is legislatively, according to Dr. Alam. The gathering of data was a legislative reaction to CMS finalizing a previous attempt to eliminate global periods.

The loss of global-period billing could be huge for dermatologists, and it could cause more economic disruption than the other MACRA-based reforms, according Clifford W. Lober, MD.

“If we were to lose our global periods, it would impact us far more than [the Merit-based Incentive Payment System] will,” said Dr. Lober, a dermatologist in Kissimmee, Fla. “The worst case under MIPS will be a 9% reduction in payments several years from now. We stand to lose significantly more than 9%, particularly from highly surgical practices, if we were to lose our global periods.”

Eliminating global-period billing also could mean higher out-of-pocket costs for patients, Dr. Lober said. “If patients have pay a [copayment] when they return for surgical follow-up visits, they simply may elect not to show up.”


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