The MMS has reviewed the new policy for global payment of
surgeries (global surgical package) proposed by the Division of
Medical Assistance. The proposal is described in hearing
announcements as redefining payment for a surgical procedure to
"include a standard package of preoperative, intraoperative, and
postoperative services. The services included within the
global surgical package would not be payable separately, regardless
of the setting in which those services were performed. In addition,
the proposed regulations describe payment for multiple surgeries
and endoscopies, add-on surgical procedures, bilateral procedures,
surgical assistants, team surgery, and co-surgery (two
surgeons)."
Regarding the specific changes, our reviewers think that several
of the changes move Medicaid to be more aligned with
Medicare. In the interest of administrative simplification,
such changes are highly desirable. However, the proposed regulation
lacks specifics on implementation practices. If the changes are
implemented inconsistently that may result in interpretations that
are not consistent with Medicare or community standards in claims
payments. Examples of these changes are described below:
The use of global surgical periods has been a standard for some
time. The proposed change will align Medicaid with Medicare
and other payers. However, it should be noted that this will
result in lower payments particularly for pediatric surgery where
the Medicare based RVUs have been understudied. In the interest of
assuring access to pediatric surgery the global rates for pediatric
surgeries should be reviewed. Historically, Medicaid's payment for
follow-up visits recognized the need and the desire to provide a
greater level of follow-up to the care of Medicaid patients who did
not have consistent social support. Thus if services are not
available for follow up care because of a lack of funding, there
may be significant compliance issues leading to poor outcomes and
increased readmissions. The Division should carefully
consider the impact of this proposal on likely readmissions.
Medicaid is proposing to follow several modifiers that are also
consistent with the billing and payment practices of Medicare and
other payers. However, the regulations do not specify the change in
payment rate due to the modifier. Most payers provide a
standard rate and do not treat each modifier for individual
consideration. The department's approach will likely cause
each case where a modifier should be appropriately applied to be
rerouted for individual consideration. Individual
consideration of a large volume of claims will likely result in a
delay of payment and an inconsistent application of the
modifier.
The MMS strongly supports the use of modifiers, particularly
modifier 25 and modifier 59 wherever applicable. However, inherent
in the use of modifiers should be an increased simplicity and a
known billing outcome. Individual consideration should not be
applied in cases where modifiers will become more routine as part
of a global system.
The MMS appreciates the opportunity to present our views on this
complex issue and look forward to working closely with the
administration on the evolution of our payment system.
