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Audit (A-05-09-00053)

Musculoskeletal Global Surgery Fees Often Did Not Reflect the Number of Evaluation and Management Services Provided

Executive Summary

Musculoskeletal global surgery fees often did not reflect the actual number of evaluation and management (E&M) services that physicians provided to beneficiaries during the global surgery periods. Using our sample results, we estimated that Medicare paid a net $49 million for E&M services that were included in musculoskeletal global surgery fees but not provided during the global surgery periods in 2007. Global surgery fees include payment for a surgical service and the related preoperative and postoperative E&M services provided during the global surgery period. The global period for major surgeries includes the day before the surgery, the day of the surgery, and the 90 days after the day of the surgery.

For 211 of the 300 sampled global surgeries, the fees did not reflect the actual number of E&M services provided. Specifically, physicians provided fewer E&M services than were included in 165 global surgery fees and provided more E&M services than were included in 46 global surgery fees. For the remaining 89 global surgeries that we sampled, either the fees reflected the actual number of E&M services provided during the global surgery periods (24 surgeries) or the surgery was 1 of multiple surgeries (65 surgeries). (For the 65 sampled surgeries that were performed as 1 of multiple surgeries, we were unable to determine whether the E&M services that physicians provided were related to the sampled surgeries or to 1 of the other surgeries performed on the same date of service. Therefore, we did not categorize these 65 sampled surgeries as errors.)

We recommended that CMS adjust the estimated number of E&M services within musculoskeletal global surgery fees to reflect the actual number of E&M services being provided to beneficiaries, which would have reduced payments in 2007 alone by an estimated $49 million, or use the results of this audit during the annual update of the physician fee schedule. CMS concurred, in part, with the recommendations but planned to conduct further analysis before proposing any changes in the number of E&M services assigned to musculoskeletal surgeries.

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