9/26/2016

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• Medtronic

• Depuy-Synthes

• SpineWave

• Begin the development of artificial technology for a defense network.

• Machines vastly facilitate human existence.

• The artificial intelligence becomes self aware.

• Rise of the machines

• John Connor organizes the resistance.

• Affordable Care Act

• PQRS, MIPRs vastly complicate physician existence.

• Efforts to decrease costs turn attention to the Global Surgical Services Package.

• Rise of the G-codes.

• Katie Orrico organizes the resistance.

• Opening salvo on the global surgical period occurred on November 13th, 2014.

• CMS finalized a policy to eliminate the 10-day and 90-day global surgical periods.

• Such a policy would have affected approximately 4,200 out of 9,900 (CPT) codes.

Source: AANS Coding Syllabus (2009 KZA, Inc.)

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• Inherent to the valuation of each CPT code is the postop care during global period.

• Implementation would have affected the valuation of CPT codes by as much as 40%.

• The inevitable result: a potential decrease in revenue for neurosurgeons by up to 25%.

• Passage of MACRA averted the elimination of the global surgical period.

• However, efforts to eliminate the global period remain on the horizon.

• MACRA tasked CMS to begin a process for collecting data to evaluate surgical global payments from a representative sample of physicians.

• On July 7, 2016, CMS released the fee schedule which will govern reimbursement for 2017.

• In the proposed rule, CMS made the additional requirement for all physicians as of January 1, 2017 to submit a new set of proposed Global Service Codes, (G-codes) on every postoperative encounter with a patient in the 10 or 90 day global period.

• MACRA authorizes CMS to withhold 5% of reimbursement.

• CMS will not impose this penalty unless compliance proves to be “not acceptable”.

• With that proposal, CMS has dramatically shifted from the MACRA legislation, which clearly states “a representative sample of physicians” to now include all physicians.

• Open comment period…

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• American College of Surgeons

• American Association of OrthopaedicSurgeons

• AANS and CNS

• A total of 25 specialties

• A surgeon’s workflow.

• “The surgeon would have to stop the timer on the first patient’s pathology review, start and stop the timer on the second and third patients when answering the phone and then restart the timer on the first patient again.” American College of Surgeons

• “This type of soul-crushing intervention will simply encourage physicians to compete for non-government payers and restrict access for Medicare and Medicaid patients.” AANS

“The fact remains that Medicare has been hemorrhaging funds as a result of misvaluedprocedural services for decades. We urge CMS to stand firm in its efforts to otherwise excise, eviscerate, and amputate bloated relative values in the fee schedule. We will be happy to assist CMS in this particular operation to rationalize RVUs.”

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Service Code Description

InpatientGXXX1 Inpatient visit, typical, per 10 minutes, included in surgical packageGXXX2 Inpatient visit, complex, per 10 minutes, included in surgical package

GXXX3 Inpatient visit, critical illness, per 10 minutes, included in surgical packageOffice or

Other Outpatient

GXXX4 Office or other outpatient visit, clinical staff, per 10 minutes, included in surgical

packageGXXX5 Office or other outpatient visit, typical, per 10 minutes, included in surgical packageGXXX6 Office or other outpatient visit, complex, per 10 minutes, included in surgical

packageVia Phone or

InternetGXXX7 Patient interactions via electronic means by physicians/NPP, per 10 minutes,

included in surgical packageGXXX8 Patient interactions via electronic means by clinical staff, per 10 minutes, included

in surgical package

• A 72-year old unrestrained automobile passenger with a severe closed head injury and an acute subdural hematoma brought to the emergency department.

• The patient has multiple injuries, a Glasgow Coma Scale score of 5T, and is intubated.

• He is taken to surgery upon admission for a craniotomy to evacuate a subdural hematoma and place an extraventricular drain (EVD) (2 hours).

• The CPT codes for craniotomy for subdural hematoma evacuation and EVD are submitted.

• On postoperative day one, the patient is examined off sedation and computed tomography (CT) scans of the head are reviewed (30 minutes of surgeon time caring for the patient).

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• Another 20 minutes is spent rounding on postoperative day two. That day, the patient’s family arrive, and the surgeon spends one hour with them discussing the severity of the injury, the surgical procedure, and the prognosis.

• The evening of postoperative day two, the surgeon responds to a series of calls over several hours regarding elevated intracranial pressure and spends 60 minutes reviewing CT scans and calling in orders.

• On postoperative day three, the intracranial pressure becomes refractory to exhaustive nonoperative measures. The surgeon decides to proceed with a decompressive hemicraniectomy (2 hours). The following day, the cycle of rounding (30 minutes) and family briefing (60 minutes) continues.

• On postoperative day five, the EVD stops working, and the surgeon replaces it (20 minutes).

• Over the first week, several hours (dozens of 10-minute intervals) are spent managing this patient.

• After four weeks in intensive care and two weeks in rehabilitation, the patient returns to the operating room for elective cranioplasty(2 hours).

• NOT INCLUDED: any care rendered to the patient within the 90-day global surgery period once he goes home but returns for follow-up visits to check on his recovery status

Day Procedure/Service Time CPT CodeCPT coding w/G-

codes

0Craniotomy evacuation of subdural hematoma placement of EVD (separate site)

3.0 h6131261210

6131261210

1 Rounds, review of CT 30 min N/C* GXXX3 × 3 units

2 Rounds, review of CT, flush EVD 20 min -- GXXX3 × 2 units

2 Family meeting 60 min -- GXXX2 × 6 units

3Remote review of CT scan, management of ICP, replacement of EVD

60 min --GXXX7 × 3 units

61210

4 Decompressive hemicraniectomy 2 h 61322 61322

5 Rounds, review of CT, ICP management 30 min -- GXXX2 × 3 units

6 Family meeting 60 min -- GXXX2 × 6 units

7 Rounds, review CT, EVD management 20 min -- GXXX2 × 2 units

8 Rounds, CT review, EVD management 15 min -- GXXX2 × 2 units

42 Cranioplasty 2 h 61246 61246

43 Rounds, CT review 10 min -- GXXX1 × 1 unit

• How to document?

• Does it have to be at the level of E&M?

• “Can I just write a postop note?”

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“We strongly challenge and expect CMS to hold providers of global surgical services to the same documentation standards and guidelines as providers of E/M services when providing a visit. The administrative burden on surgeons should be no different and certainly no less than that on non-surgeons when it comes to documenting a visit with a patient.”

“If many surgeons currently use minimal documentation when they provide a post-operative visit that is no excuse for expecting the same inadequate level of documentation going forward. To require anything less than the same level of documentation for all clinicians providing E/M services would be irresponsible and unfair and would defeat the very purpose of documenting the actual types and extent of these services in the post-operative period.”

• This case is a typical scenario for any neurosurgeon on trauma call.

• The current global allows the neurosurgeon to submit four CPT codes and then focus on caring for the patient and communicating with the family.

• With the new G-code system, the surgeon must submit four CPT codes and 40 or more G-codes when the entire intensive care unit stay is included.

• Every G-code will require additional supportive documentation.

• Surgeons will need to submit additional documentation to their compliance departments,

• Expend an inordinate amount of time collecting documentation and reconciling it with G-codes before proceeding with submission.

• 69-year-old woman with the worst headache of her life along with syncopal episode.

• CT demonstrated SAH with hydrocephalus

• CTA demonstrated a left PCOM.

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• Following day undergoes placement of right EVD and craniotomy for clip ligation of left PCOM.

• Vasospasm/ Angioplasty

• VPS

Day Procedure/Service TimeCPT Code

CPT coding w/G-codes

-1Evaluation, review CT and CTA, discuss plan for surgery

60 min 99255 99255

0Left craniotomy for clipping of aneurysm, right frontal EVD placement

6.0 h6169761210

6169761210

1 Rounds, review of CT 30 min N/C* GXXX3 × 3 units2 Rounds, discussion with ICU & Endocrine teams 30 min -- GXXX3 × 3 units

3Rounds, initiate antiseizure treatment and EEG, neurology consultation

50 min --GXXX3 × 2 unitsGXXX7 × 3 units

4 Rounds, review Neurology recommendations 30 min -- GXXX3 × 3 units5 Rounds, EVD management 30 min -- GXXX2 × 3 units6 Rounds, review CT, EVD management 30 min -- GXXX2 × 3 units7 Rounds, EVD management 20 min -- GXXX2 × 2 units

8Rounds, CT review, angiography and treatment of left MCA spasm

4 h616403622436226

616403622436226

GXXX3 × 6 units

9 Rounds, CT review45

minutes-- GXXX2 × 3 units

10Rounds, CT review, angiography and treatment of bilateral ACA spasm, with exam after angiography and discussion with family

5 h61650

+61651+36226

61650+61651

+336226GXXX3 × 6 units

11 Rounds, EVD management, review CT 30 min -- GXXX3 × 3 unit12 Rounds, EVD management 30 min -- GXXX2 × 3 units13 Rounds, EVD management 20 min -- GXXX2 × 2 units

14 Rounds, VP shunt placement 2 h 6222362223

GXXX2 × 2 units

57ED evaluation, shunt removal with EVD placement

3 h 6225662256

GXXX3 × 3 unit58 Rounds, EVD management 30 min -- GXXX2 × 3 units59 Rounds, EVD management 20 min -- GXXX2 × 2 units60 Rounds, EVD management 20 min -- GXXX2 × 2 units61 Rounds, EVD management 20 min -- GXXX2 × 2 units62 Rounds, EVD management 20 min -- GXXX2 × 2 units63 Rounds, EVD management 20 min -- GXXX2 × 2 units64 Rounds, EVD management 20 min -- GXXX2 × 2 units65 Rounds, EVD management 20 min -- GXXX2 × 2 units66 Rounds, EVD management 20 min -- GXXX2 × 2 units67 Rounds, EVD management 20 min -- GXXX2 × 2 units68 Rounds, EVD management 20 min -- GXXX2 × 2 units

69Rounds, EVD management, VP shunt replacement

2 h 6222362223

GXXX2 × 2 units70 Rounds, CT review 20 min -- GXXX1 × 2 units

• 12 CPT codes for the entire hospital stay.

• The new G-code system, the surgeon must submit 12 CPT codes and 72 or more G-codes

• How do you record, document and submit 72 additional G-codes?

• Imagine multiplying these numbers by an entire neurosurgery census.

• Over a week, the number of CPT codes skyrockets from 10-15 to several hundred G-codes

• It is impossible to maintain accurate collection, documentation and submission without compromising patient care.

• The G-code system would distract every surgeon from their primary responsibility: the patient.

• RUC estimates 500 MILLION new claims.

• There is one solution…

• Current G-code proposal will fail.

• It is impossible to implement.

• It will yield incomplete and unreliable results.

• Not validated or even tested.

• If CMS insists on going this route, one year from now we are going to be in the same place.

• Data interpretation: ice cream and drownings.

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• Scale back the plan and adopt a more reasonable data collection and reporting process.

• Build on existing mechanisms by using the RUC survey process and tracking postop visits using CPT Code 99024.

• There are only 110 10-day global and 149 90-day global codes performed more than 10,000 times.

• Seems reasonable for CMS to identify a targeted subset of CPT codes that meet a minimum utilization threshold.

• Then identify an appropriate representative sample of physicians from whom to collect data.

“We believe that this project is of sufficient value and magnitude that it merits universal application, as proposed. We understand that some critics may object that this approach is contrary to the legislative language to collect data from “a representative sample of physicians,” because a sample is a subset of an entire population

In response, we note that not every physician will be subject to this data collection effort. Only those who provide 10- and 90-day global surgical services to Medicare patients will be required to do so. That is a subset of the entire physician population and, from our perspective, consistent with the statutory mandate to use “a representative sample of physicians.”

• Rise of the G-codes is the opening salvo on the global surgical period.

• CMS has tipped their hand.

• The G-code not efficient, it is overly burdensome and impractical… this has to be intentional.

• What will be the unintended consequences that will result from this direction?

“Never tear down a wall until you know who built it

and for what purpose.”

Robert Frost

9/26/2016

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• Begin the development of artificial technology for a defense network.

• Machines vastly facilitate human existence.

• The artificial intelligence becomes self aware.

• Rise of the machines

• John Connor organizes the resistance.

• Affordable Care Act

• PQRS, MIPRs vastly complicate physician existence.

• Efforts to decrease costs turn attention to the Global Surgical Services Package.

• Rise of the G-codes.

• Katie Orrico organizes the resistance.

• Join the resistance

• Write your congressman or senator.

• Support the NeuroPAC

• A war of attrition.

• Expansion of the representative sample.

• Penalties for non-compliance.

• Increasing number of neurosurgeons will begin to stop taking Medicare.

• Stay united, stay aware, be prepared.