Unpacking the Global Package

Does the Global Package need unpacking? In order to answer this question, it’s important look at the value (RVU or Relative Value Unit) attached to certain procedures.

The Global Package has applied to over 4,000 physician services since 1992. Over time, providers have been concerned about the valuation of many of these services. Inflation and improvements to certain procedures since 1992 due to new technologies necessitate fewer post-operative visits as were previously valued. In recent years, CMS (Centers for Medicare and Medicaid Services) has proposed to revise the global package many times. In the 2023 Proposed rule, CMS had said they would take comments on revising the Global Package.

Prior to the final payment rule for 2023, CMS evaluated those comments and data surrounding E/M services performed in conjunction with specific procedures and the types of physicians to calculate the direct and indirect percentages as well as the indirect practice cost index, found in the Physician Expense (PE) methodology.

Data Collection

As with any decision of this magnitude, critical data needs to be collected. As part of the data collection,  information from the 2019 RAND report was utilized. In the report  claims-based and survey-based data looked at the number of postoperative visits that occurred during the 10-and 90-day global periods for specific procedures, and they looked at the level of those visits. The data reported did show that the number of E/M visits performed compared to the expected was only matching 4 percent of 10-day global package procedures and 38 percent of 90-day global package procedures. However, many had voiced concerns about the validity of the sources for this data collection; also, since the post-operative tracking code 99024 is not required to be reported on all claims for all states, it cannot clearly be seen how many post-operative visits were performed with the data collected. Currently, only 9 states are still required to report code 99024 for tracking purposes, and those states are: Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island (Learn more about these requirements at CMS.GOV)

CMS stated that based on the comments they received and the data from RAND:

“We did not receive new data that might either affirm or contradict RAND’s overall findings regarding E/M performance. We agree with commenters’ observations that we have spent many years collecting and analyzing data regarding E/M performance in response to the MACRA requirements and other public concerns about the valuation of globals. While we will continue to evaluate potential sources of data regarding E/M performance, we agree with commenters who suggest that the overall lack of transparency within global packages can make identifying the nature of postoperative care provision difficult and continues to call into question the accuracy of globals that have been valued through standard valuation processes.”

Although it was not decided to completely unpack the global package, there was a specific code-set of note for General surgery that received a review. In April of 2021, the existing surgical codes for Hernia repair were reviewed and certain codes were deleted with new codes added effective Jan 1, 2023. For example, the RUC (RVS Update Committee) reviewed code 49565 for a Repair recurrent incisional or ventral hernia; reducible, to identify utilization in both the inpatient and outpatient setting.  Effective Jan 1, 2023 CPT®️ decided to create a new set of codes that would value if the hernia is initial or recurrent, reducible or strangulated, and the total length of the hernia needing repair. These new codes have a 0 day global period as identified by CPT.

It is worth noting that the calculations recommended by the RUC for many of the codes were not met with a complete agreement based on the 23 hour policy CMS feels was misapplied in various instances. We recommend taking a look at the calculations and comments in the full report by CMS. (87 FR 69476)

Today’s Global Package

With many services still utilizing the global package, it becomes critical to revisit it to fully understand what is included and when additional E/M services are warranted. When you examine all of the codes that carry a global concept you will see three different types based on the days included in a package.

  •  0-Day Global Package procedures indicate that the procedure includes items needed to evaluate the patient for the procedure and any necessary Preoperative and Postoperative work on that day.
  • 10-Day Global Package procedures indicate that there will be necessary Evaluation and Management to decide to perform a procedure on that day the patient is seen and the post operative work will be conducted for 10 days after the procedure, which equals a total of 11 days including the day of the procedure.
  • 90-Day Global Package procedures indicate that there will be additional criteria not found in the first two packages. This package is unlike the first two, in that it is used for services that constitute Major Surgery by the Insurance payer

NOTE: The designation of Minor and Major services by CMS is not used to constitute the definitions of Minor and Major surgery found in the Evaluation and Management guidelines for Risk

“The classification of surgery into minor or major is based on the common meaning of such terms when used by trained clinicians, similar to the use of the term “risk.” These terms are not defined by a surgical package classification”

-2021 E/M Revisions, AMA

Global Package Services

The following components are part of any service that has a global concept:

  • Pre-operative visits after the decision is made to operate. For major procedures (90-day global services), this includes pre-operative visits the day before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery.
  • Intra-operative services that are normally a usual and necessary part of a surgical procedure.
  • All additional medical or surgical services required of the surgeon during the post-operative period of the surgery because of complications, which do not require additional trips to the operating room.
  • Follow-up visits during the post-operative period of the surgery that are related to recovery from the surgery
  • Post-surgical pain management by the surgeon
  • Supplies, except for those identified as exclusions
  • Miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes

This is for CMS package requirements. CPT® may have different components and rules.

This means that anytime you decide to perform a surgery, you will need to know what’s included from both a payment and reimbursement perspective. You will still get reimbursed for all the components of the service but in a bundled or packaged payment.

With rising healthcare operating costs, it’s only natural that Physicians and Administrators are interested in capturing the highest reimbursements possible to stay in business and continue to care for their patients. There are legitimate ways to do this, including having coders on staff who know additional opportunities you may be missing and receiving education from consultants and experts in documentation requirements.  

Contact an advisor at Spark Advisory Network to schedule a session today.