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Audit (A-05-07-00077)

04-20-2009
Nationwide Review of Evaluation and Management Services Included in Eye and Ocular Adnexa Global Surgery Fees for Calendar Year 2005

Executive Summary

Eye global surgery fees often did not reflect the number of evaluation and management (E&M) services that physicians provided to Medicare beneficiaries during global surgery periods. 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 period for major surgeries includes the day before the surgery, the day of the surgery, and the 90 days immediately following the day of the surgery. In determining a global surgery fee, CMS estimates the number of E&M services that a physician provides to a typical beneficiary during the global surgery period.

Based on our sample results, we estimated that Medicare paid $97.6 million for E&M services that were included in eye global surgery fees but not provided during the global surgery periods in calendar year 2005. The global surgery fees did not reflect the number of E&M services provided to beneficiaries because CMS had not adjusted or recently adjusted the relative value units for most of the sampled surgeries.

We recommended that CMS consider (1) adjusting the estimated number of E&M services within eye global surgery fees to reflect the number of E&M services actually being provided to beneficiaries, which may reduce payments by an estimated $97.6 million, or (2) using the financial results of this audit, in conjunction with other information, during the annual update of the physician fee schedule. In written comments on our draft report, CMS acknowledged the merit of our findings but believed that it would be prudent to conduct further analysis before proposing any changes in the number of E&M services assigned to eye surgeries.

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