The Centers for Medicare and Medicaid Services leads the way in many areas of healthcare policy, including reimbursement. Here are 20 things for gastroenterologists to know about Medicare reimbursement in the GI field.
Physician reimbursement
1. CMS reimburses physicians under the Medicare Physician Fee Schedule. In July, CMS released the CY 2015 Physician Fee Schedule Proposed Rule.
2. The proposed changes do not include payment updates for lower endoscopy, including colonoscopy, despite rigorous advocacy efforts by the AGA and its sister societies: the American College of Gastroenterology and American Society for Gastrointestinal Endoscopy. The three societies released a joint statement urging CMS to allow for a more transparent rulemaking process and improved colonoscopy reimbursement.
3. The proposed rule also includes an increase in Physician Quality Reporting System requirements. In 2014, physicians were only required to report three PQRS quality measures to avoid a 2 percent payment reduction in 2016.
4. The 2015 proposed rule would require eligible professionals to report nine quality measures across three domains for at least 50 percent of Medicare Part B fee-for-service patients.
Ambulatory surgery center reimbursement and hospital outpatient department reimbursement
5. In its CY 2015 Hospital Outpatient Prospective Payment System and Ambulatory Surgery Center Proposed Rule, CMS proposed a 2.1 percent increase in HOPD reimbursement. This increase is based on projected hospital market basket increase of 2.7 percent minus both a 0.4 percent adjustment for multi-factor productivity and a 0.2 percent adjustment required by law.
6 In the CY 2015 proposed rule, CMS suggests a 1.2 percent increase for ASC reimbursement.
7. ASC payments are updated each year to account for inflation by the percentage increase in the Consumer Price Index for all urban consumers. Medicare also specifies a multi-factor productivity adjustment to the ASC annual update.
8. For 2015, the Consumer Price Index update is projected to be 1.7 percent and the multifactor productivity adjustment is projected to be 0.5 percent for CY 2015. The MFP-adjusted CPI-U update would be 1.2 percent for CY 2015.
9. The proposed rule would also add a new colonoscopy measure to the ASC Quality Reporting Program. The new measure, Facility Seven-Day Risk Standardized Hospital Visit Rate After Outpatient Colonoscopy, will be used for the CY2017 payment determination, based on claims from July 1, 2014 to June 30, 2015.
Upper GI/endoscopy
10. CMS instituted payment cuts to 2014 Medicare reimbursement rates for upper GI/endoscopy procedures, despite the combined efforts of the American College of Gastroenterology, American Gastroenterological Association and American Society for Gastrointestinal Endoscopy.
11. Medicare reimbursement for upper GI/endoscopy procedures was also reduced between 2012 and 2013. Here are seven common procedures with Medicare Fee Schedule physician payment in 2012 and 2013, according to the American College of Gastroenterology.
Upper GI endoscopy, diagnosis (HCPCS 43235)
2012: $148.06
2013: $145.10
Upper GI endoscopy, biopsy (HCPCS 43239)
2012: $174.61
2013: $171.12
Upper GI endoscopy w/us fn bx (HCPCS 43242)
2012: $429.89
2013: $421.29
Upper GI endoscopy/ligation (HCPCS 43244)
2012: $299.87
2013: $293.87
Operative upper GI endoscopy (HCPCS 43247)
2012: $203.89
2013: $199.81
Upper GI endoscopy/guide wire (HCPCS 43248)
2012: $191.63
2013: $187.80
Operative upper GI endoscopy (HCPCS 43255)
2012: $286.94
2013: $281.20
Colonoscopy
12. The 2015 proposed rule would redefine colorectal cancer screening colonoscopy to include anesthesia. As a result, Medicare Part B deductible and coinsurance will be waived for anesthesia services charged separately. The GI societies appreciate this move towards eliminating barriers to colorectal cancer screening, but they express disappointment that CMS has not made the same move to eliminate coinsurance for colonoscopy including polyp removal.
13. CMS' 2015 proposed rule does not include payment values for colonoscopy, but will likely release changes to lower endoscopy code values with its November final rule. GI societies will have little time to comment on new values before they go into effect on Jan. 1, 2015. The AGA, ACG and ASGE are working to improve accuracy in GI endoscopic procedure valuation through CMS and the AMA Relative Value Update Committee.
14. Here are 21 statistics on Medicare facility fees and Medicare fee schedule physician payments for colonoscopies performed in ASCs and HOPDs in 2013, according to the American College of Gastroenterology.
Diagnostic colonoscopy (HCPCS 45378)
• ASC: $380.16
• HOPD: $677.49
• Physician: $216.15
Colonoscopy and biopsy (HCPCS 45380)
• ASC: $380.16
• HOPD: $677.49
• Physician: $258. 51
Colonoscopy and submucous inj. (HCPCS 45831)
• ASC: $380.16
• HOPD: $677.49
• Physician: $245.18
Colonoscopy/control bleeding (HCPCS 45382)
• ASC: $370.50
• HOPD: $677.49
• Physician: $329.23
Lesion removal colonoscopy (HCPCS 45383)
• ASC: $380.16
• HOPD: $677.49
• Physician: $334.24
Lesion removal colonoscopy (HCPCS 45384)
• ASC: $380.16
• HOPD: $677.49
• Physician: $269.52
Lesion removal colonoscopy (HCPCS 45385)
• ASC: $380.16
• HOPD: $677.49
• Physician: $306.55
15. Here are 30 statistics on colonoscopy facility payment in 2013 and 2014 and the percent change between the two years, according to the 2014 Estimated Medicare Reimbursement Rates for GI Services report from the American Gastroenterological Association.
Diagnostic colonoscopy (CPT code 45378)
• Facility payment 2014: $210.58
• Facility payment 2013: $220.45
• Percent change: -4 percent
Colonoscopy w/fb removal (CPT code 45379)
• Facility payment 2014: $264.34
• Facility payment 2013: $275.90
• Percent change: -4 percent
Colonoscopy and biopsy (CPT code 45380)
• Facility payment 2014: $251.41
• Facility payment 2013: $262.97
• Percent change: -4 percent
Colonoscopy submucous injection (CPT code 45381)
• Facility payment 2014: $238.48
• Facility payment 2013: $249.71
• Percent change: -4 percent
Colonoscopy/control bleeding (CPT code 45382)
• Facility payment 2014:
• Facility payment 2013:
• Percent change:
Lesion removal colonoscopy (CPT code 45383)
• Facility payment 2014: $327.27
• Facility payment 2013: $341.22
• Percent change: -4 percent
Lesion removal colonoscopy (CPT code 45384)
• Facility payment 2014: $263.31
• Facility payment 2013: $274.54
• Percent change: - 4 percent
Lesion removal colonoscopy (CPT code 45385)
• Facility payment 2014: $298.70
• Facility payment 2013: $311.96
• Percent change: -4 percent
Colonoscopy dilate stricture (CPT code 45386)
• Facility payment 2014: $258.55
• Facility payment 2013: $270.46
• Percent change: -4 percent
Bundled payments
16. On Jan. 31, 2013 CMS announced the providers participating in its Bundled Payments for Care Improvement Initiative. The BPCI initiative is built on four different models including:
• Retrospective acute care hospital stay only
• Retrospective acute care hospital stay plus post-acute care
• Retrospective post-acute care only
• Prospective acute care hospital stay only
17. CMS' implementation plan includes two phases for BPCI models 2, 3 and 4. Read more on Becker's Hospital Review.
18. In light of the emergent bundled payments trend, the AGA released a model for colonoscopy bundled payments, which includes:
• Pre-procedure period: includes physician/staff consultation and bowel preparation instruction
• Procedure: includes fees for colonoscopy, anesthesia, facility and pathology
• Post-procedure: communication with patient and repeat procedures if post-colonoscopy bleeding occurs or bowel prep leads to incomplete procedure
Value-based reimbursement
19. The proposed rule also includes an expansion of the physician Value-Based Payment Modifier program. The VBPM will continue to be linked to eligible physicians' participation in PQRS. Failure to satisfactorily participate in PQRS could lead to a payment reduction of 6 percent.
20. Here are five important dates regarding the shift from fee-for-service reimbursement to value-based payment, according to the American Gastroenterological Association.
• Spring 2014 to Sept. 30, 2014. Period to participate in the Physician Quality Reporting System to avoid payment penalties in 2016.
• Jan. 1, 2015. Payment will be adjusted based on value-based payment modifiers for groups of 100 or more physicians (based on 2013 performance).
• February 2015. Estimated deadline to submit claims-based reporting for the 2014 PQRS reporting period.
• August 2015. CMS sends QRURs to all physician groups and solo practitioners.
• Jan. 1, 2016. Payment is adjusted based on VBPM for physicians in groups of 10 to 99 and groups of 100 or more (based on 2014 performance).
CPT Copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
More articles on gastroenterology:
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Physician reimbursement
1. CMS reimburses physicians under the Medicare Physician Fee Schedule. In July, CMS released the CY 2015 Physician Fee Schedule Proposed Rule.
2. The proposed changes do not include payment updates for lower endoscopy, including colonoscopy, despite rigorous advocacy efforts by the AGA and its sister societies: the American College of Gastroenterology and American Society for Gastrointestinal Endoscopy. The three societies released a joint statement urging CMS to allow for a more transparent rulemaking process and improved colonoscopy reimbursement.
3. The proposed rule also includes an increase in Physician Quality Reporting System requirements. In 2014, physicians were only required to report three PQRS quality measures to avoid a 2 percent payment reduction in 2016.
4. The 2015 proposed rule would require eligible professionals to report nine quality measures across three domains for at least 50 percent of Medicare Part B fee-for-service patients.
Ambulatory surgery center reimbursement and hospital outpatient department reimbursement
5. In its CY 2015 Hospital Outpatient Prospective Payment System and Ambulatory Surgery Center Proposed Rule, CMS proposed a 2.1 percent increase in HOPD reimbursement. This increase is based on projected hospital market basket increase of 2.7 percent minus both a 0.4 percent adjustment for multi-factor productivity and a 0.2 percent adjustment required by law.
6 In the CY 2015 proposed rule, CMS suggests a 1.2 percent increase for ASC reimbursement.
7. ASC payments are updated each year to account for inflation by the percentage increase in the Consumer Price Index for all urban consumers. Medicare also specifies a multi-factor productivity adjustment to the ASC annual update.
8. For 2015, the Consumer Price Index update is projected to be 1.7 percent and the multifactor productivity adjustment is projected to be 0.5 percent for CY 2015. The MFP-adjusted CPI-U update would be 1.2 percent for CY 2015.
9. The proposed rule would also add a new colonoscopy measure to the ASC Quality Reporting Program. The new measure, Facility Seven-Day Risk Standardized Hospital Visit Rate After Outpatient Colonoscopy, will be used for the CY2017 payment determination, based on claims from July 1, 2014 to June 30, 2015.
Upper GI/endoscopy
10. CMS instituted payment cuts to 2014 Medicare reimbursement rates for upper GI/endoscopy procedures, despite the combined efforts of the American College of Gastroenterology, American Gastroenterological Association and American Society for Gastrointestinal Endoscopy.
11. Medicare reimbursement for upper GI/endoscopy procedures was also reduced between 2012 and 2013. Here are seven common procedures with Medicare Fee Schedule physician payment in 2012 and 2013, according to the American College of Gastroenterology.
Upper GI endoscopy, diagnosis (HCPCS 43235)
2012: $148.06
2013: $145.10
Upper GI endoscopy, biopsy (HCPCS 43239)
2012: $174.61
2013: $171.12
Upper GI endoscopy w/us fn bx (HCPCS 43242)
2012: $429.89
2013: $421.29
Upper GI endoscopy/ligation (HCPCS 43244)
2012: $299.87
2013: $293.87
Operative upper GI endoscopy (HCPCS 43247)
2012: $203.89
2013: $199.81
Upper GI endoscopy/guide wire (HCPCS 43248)
2012: $191.63
2013: $187.80
Operative upper GI endoscopy (HCPCS 43255)
2012: $286.94
2013: $281.20
Colonoscopy
12. The 2015 proposed rule would redefine colorectal cancer screening colonoscopy to include anesthesia. As a result, Medicare Part B deductible and coinsurance will be waived for anesthesia services charged separately. The GI societies appreciate this move towards eliminating barriers to colorectal cancer screening, but they express disappointment that CMS has not made the same move to eliminate coinsurance for colonoscopy including polyp removal.
13. CMS' 2015 proposed rule does not include payment values for colonoscopy, but will likely release changes to lower endoscopy code values with its November final rule. GI societies will have little time to comment on new values before they go into effect on Jan. 1, 2015. The AGA, ACG and ASGE are working to improve accuracy in GI endoscopic procedure valuation through CMS and the AMA Relative Value Update Committee.
14. Here are 21 statistics on Medicare facility fees and Medicare fee schedule physician payments for colonoscopies performed in ASCs and HOPDs in 2013, according to the American College of Gastroenterology.
Diagnostic colonoscopy (HCPCS 45378)
• ASC: $380.16
• HOPD: $677.49
• Physician: $216.15
Colonoscopy and biopsy (HCPCS 45380)
• ASC: $380.16
• HOPD: $677.49
• Physician: $258. 51
Colonoscopy and submucous inj. (HCPCS 45831)
• ASC: $380.16
• HOPD: $677.49
• Physician: $245.18
Colonoscopy/control bleeding (HCPCS 45382)
• ASC: $370.50
• HOPD: $677.49
• Physician: $329.23
Lesion removal colonoscopy (HCPCS 45383)
• ASC: $380.16
• HOPD: $677.49
• Physician: $334.24
Lesion removal colonoscopy (HCPCS 45384)
• ASC: $380.16
• HOPD: $677.49
• Physician: $269.52
Lesion removal colonoscopy (HCPCS 45385)
• ASC: $380.16
• HOPD: $677.49
• Physician: $306.55
15. Here are 30 statistics on colonoscopy facility payment in 2013 and 2014 and the percent change between the two years, according to the 2014 Estimated Medicare Reimbursement Rates for GI Services report from the American Gastroenterological Association.
Diagnostic colonoscopy (CPT code 45378)
• Facility payment 2014: $210.58
• Facility payment 2013: $220.45
• Percent change: -4 percent
Colonoscopy w/fb removal (CPT code 45379)
• Facility payment 2014: $264.34
• Facility payment 2013: $275.90
• Percent change: -4 percent
Colonoscopy and biopsy (CPT code 45380)
• Facility payment 2014: $251.41
• Facility payment 2013: $262.97
• Percent change: -4 percent
Colonoscopy submucous injection (CPT code 45381)
• Facility payment 2014: $238.48
• Facility payment 2013: $249.71
• Percent change: -4 percent
Colonoscopy/control bleeding (CPT code 45382)
• Facility payment 2014:
• Facility payment 2013:
• Percent change:
Lesion removal colonoscopy (CPT code 45383)
• Facility payment 2014: $327.27
• Facility payment 2013: $341.22
• Percent change: -4 percent
Lesion removal colonoscopy (CPT code 45384)
• Facility payment 2014: $263.31
• Facility payment 2013: $274.54
• Percent change: - 4 percent
Lesion removal colonoscopy (CPT code 45385)
• Facility payment 2014: $298.70
• Facility payment 2013: $311.96
• Percent change: -4 percent
Colonoscopy dilate stricture (CPT code 45386)
• Facility payment 2014: $258.55
• Facility payment 2013: $270.46
• Percent change: -4 percent
Bundled payments
16. On Jan. 31, 2013 CMS announced the providers participating in its Bundled Payments for Care Improvement Initiative. The BPCI initiative is built on four different models including:
• Retrospective acute care hospital stay only
• Retrospective acute care hospital stay plus post-acute care
• Retrospective post-acute care only
• Prospective acute care hospital stay only
17. CMS' implementation plan includes two phases for BPCI models 2, 3 and 4. Read more on Becker's Hospital Review.
18. In light of the emergent bundled payments trend, the AGA released a model for colonoscopy bundled payments, which includes:
• Pre-procedure period: includes physician/staff consultation and bowel preparation instruction
• Procedure: includes fees for colonoscopy, anesthesia, facility and pathology
• Post-procedure: communication with patient and repeat procedures if post-colonoscopy bleeding occurs or bowel prep leads to incomplete procedure
Value-based reimbursement
19. The proposed rule also includes an expansion of the physician Value-Based Payment Modifier program. The VBPM will continue to be linked to eligible physicians' participation in PQRS. Failure to satisfactorily participate in PQRS could lead to a payment reduction of 6 percent.
20. Here are five important dates regarding the shift from fee-for-service reimbursement to value-based payment, according to the American Gastroenterological Association.
• Spring 2014 to Sept. 30, 2014. Period to participate in the Physician Quality Reporting System to avoid payment penalties in 2016.
• Jan. 1, 2015. Payment will be adjusted based on value-based payment modifiers for groups of 100 or more physicians (based on 2013 performance).
• February 2015. Estimated deadline to submit claims-based reporting for the 2014 PQRS reporting period.
• August 2015. CMS sends QRURs to all physician groups and solo practitioners.
• Jan. 1, 2016. Payment is adjusted based on VBPM for physicians in groups of 10 to 99 and groups of 100 or more (based on 2014 performance).
CPT Copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
More articles on gastroenterology:
Does IBD up the risk of heavy opioid use?
Breaking down the cost of Hepatitis C treatment: 7 things to know
How busy are gastroenterologists?