A proposal tucked into the physician fee schedule issued last week includes a new payment mechanism that could improve follow-up care in nursing homes for post-surgical patients, including those with hip or other fractures.
While details are still sparse as the Centers for Medicare & Medicaid Services solicits comments on its idea, one physician expert said incentivizing specialists to provide on-site visits to nursing home residents is overdue.
Currently, nursing home employees often manage a resident’s post-surgical care, relying on the facility’s attending physician and social work staff to arrange transportation to a surgeon’s office for needed follow-ups. That not only requires recovering patients to spend up to half the day out of their facility, it increases the facility’s expenses and puts more burden on overtaxed nursing home staff, said Rajeev Kumar, MD, AMDA’s 2024-2025 president and medical director for Optum at Home.
“The challenge is that nursing home visits are not as well compensated as those in a clinic or hospital,” Kumar told McKnight’s Long-Term Care News Thursday. “That’s why we struggle to get specialists in.”
In its 2,248-page proposed physician fee schedule for 2025, CMS said it is reconsidering how it reimburses for global services under certain procedural codes. The changes could allow physicians to collect for driving to see nursing home patients, even if there’s just one to treat in a given building. They could also allow surgeons, including orthopedists, to reassign care and reimbursement to another doctor after hospital discharge, including a nurse practitioner that might be more likely to be on site at a nursing home, Kumar said.
CMS said its latest request for comment is part of ongoing work to develop payment mechanisms that can improve the “accuracy of valuation and payment for the services furnished by physicians and other healthcare professionals.” The agency said it wanted to look at codes that affect post-discharge care in nursing homes, the community and other post-acute environments as it continues to explore new models of care that account for social determinants of health, such as lack of transportation.
“We are seeking comments on ways to identify specific services and to recognize possible barriers to improved access to these kinds of high-value, potentially underutilized services by Medicare beneficiaries,” CMS said. “We are seeking public comment to understand more clearly how often evidence-based care for persons with fractures, for example, is not provided and the reasons for this, and how recent or new PFS codes, or their revaluation, might help resolve specific barriers to its provision.”
Broken bone care lacking?
Fractures are a common reason for surgical intervention among the elderly. Kumar cited data showing residents have a 23% chance of a hip fracture over 10 years. More generally, there are more than 300,000 hip fractures among seniors over 65 annually, and patients are more likely to need skilled care and rehabilitation services the older they are.
Currently, the physician fee schedule includes codes that pay for various components of care to manage patients with fractures over a course of treatment, such as transitional care management and other care management services, evaluation and management visits (including an add-on for office or outpatient visits) and community health integration.
“Interested parties have indicated that orthopedic surgeons, skilled nursing facilities, and other practitioners and providers may not be providing comprehensive patient-centered fracture management care for quality, payment, or administrative reasons, and that there is inadequate ‘hand-off’ when postdischarge fracture care is transferred to practitioners in the community,” CMS noted.
Path to more pay
In its 2025 new rule, CMS is proposing new coding that might be used to bill for managing fractures under a treatment plan, including a new, post-operative add-on code under which doctors could earn additional reimbursement.
Kumar was especially supportive of allowing post-op reimbursement to flow from one specialist to another, especially if the initial surgeon doesn’t have the bandwidth to attend to patients scattered across different nursing homes. It could improve both outcomes and quality of life for recovering nursing home residents, he noted.
CMS called the current lack of adequate on-site follow-up care a “systemic disconnect” that may miss underlying diagnoses and needed follow-up treatment because “global surgical periods focus on acute fracture recovery rather than addressing osteoporosis.”
“We are interested in hearing if the proposed global postop add-on code could help resolve these issues,” CMS said.
