The comments flooded in after the CMS proposed in July that surgeons collect data on every 10 minutes of perioperative activity. “Undue burden,” the American Medical Association called the suggested requirement. 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 do it?
As the agency explains in its 2017 Medicare Physician Fee Schedule (PDF), the CMS pays for certain services, like 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, plus post-operative visits, as well as pain management after surgery, plus 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 it-didn'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 10-day 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 2015 Medicare Access and CHIP Reauthorization Act, prohibited that transition, but it did require 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 the 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 increments,” as either typical, complex or critical inpatient or outpatient visits, the CMS said. Typical activities included tasks like 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 “because we believe it provides us 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 has numerous concerns regarding this expansive collection of data,” the AMA wrote in a letter to CMS Acting Administrator Andy Slavitt. It 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 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."