CMS wants surgeons to code every 10 minutes of certain work. Some aren’t happy about it.

11:30 AM – September 13, 2016 – Advisory Board

Many medical organizations are protesting a new CMS proposal that would require surgeons to document every 10 minutes of their post-operative patient care activities for certain procedures.


According to Medscape, Medicare reimburses for about 4,200 surgical procedures via global surgical “packages”—lump sum payments for 10 or 90 days that include funds for pre-op care, surgery, and post-op care.

In the final rule for the 2015 physician fee schedule, CMS proposed scaling back global packages so that doctors instead would bill separately for post-op visits after the day of surgery, out of concern that the packages cover a higher-than-average number of post-op visits. However, Congress in the Medicare Access and CHIP Reauthorization Act (MACRA) late last year blocked that CMS proposal, but directed the agency to collect more information about post-op patient visits.

In July 2016, CMS in its proposed Medicare Part B fee schedule for 2017 put forward its plan to gather that data by requiring all surgeons to report one of eight G-codes—care codes that indicate the type and complexity of the visit—for every 10 minutes of post-op care. For instance, GXXX1 would represent a typical inpatient visit, GXXX2 would a complex inpatient visit, and GXXX3 would represent an inpatient visit related to a critical illness.

MACRA authorizes CMS to withhold up to 5 percent of reimbursement from physicians who do not report G-codes.


Many medical groups, including the American College of Surgeons (ACS), the American Association of Orthopaedic Surgeons, the American Association of Neurological Surgeons, and the American Medical Association (AMA), have filed complaints with CMS against the proposal.

In a letter to CMS, ACS indicated that patient care cannot easily be coded into 10 minutes increments. For example, a surgeon may review patient files throughout the day, switching from task to task.

“The surgeon would have to stop the timer on the first patient’s pathology review, start and stop timers on the second and third patients when answering the phone, and then restart the timer on the first patient in the office,” the letter said. “This often happens many times in a day.”

The American Association of Neurological Surgeons and the Congress of Neurological Surgeons in a separate letter to CMS said that surgeons would burn out if they had to track every 10 minutes of their non-OR time. In the letter, the groups quoted an unnamed neurosurgeon who called the proposal “soul-crushing.”

Meanwhile, AMA said, “Asking physicians and their staff to use 10-minute increments to document all their non-operating room patient care activities is by itself an incredible burden, and especially so during MACRA implementation—the most significant payment system change in 25 years.”

AMA called on CMS to limit the data collection process to only certain services, noting that “many surgical codes are low volume, which would make it difficult to find a meaningful sample.” The group also urged the agency “to adopt a data collection method that is limited in scope and uses a representative sample to better understand the necessary post-operative visits” (Gooch, Becker’s Hospital CFO, 9/9; Lowes, Medscape, 9/8; AMA statement, 9/9; RAND report, accessed 9/12).

How to improve physician documentation

The transition to ICD-10, value-based purchasing, and emerging public quality metrics make accurate documentation more critical than ever. That’s why over 80 percent of hospitals have a clinical documentation program in place and are working to correct inaccurate documentation.

However, most are investing significant resources in a strategy that focuses on querying rather than sustainable changes in physician behavior. This leaves a lot of money on the table—a 250-bed hospital with superior documentation performance captures $5 million in revenue in a single year over average-performing peers.

We developed the Physician Documentation Improvement Toolkit with strategic and project management resources that map to the four key steps physician champions must execute to advance documentation improvement.


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Drue De Angelis

Drue is Managing Partner for The De Angelis Group, Executive Search firm exclusively for the Ortho & Spine industry.

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