This Week – December 7, 2013

This Week in Washington DC:

  1. CMS Releases Final 2014 Medicare Physician Fee Schedule Rates and Other Policy Changes:
    Upper GI Procedures Cut Significantly
  2. CMS Releases Final 2014 Hospital Outpatient Department and Ambulatory Surgical Center Payment Rates and Policy Changes

CMS Slashes Upper GI in the 2014 Medicare Physician Fee Schedule

On Wednesday, November 27th the Centers for Medicare and Medicaid Services (CMS) released the final 2014 Medicare physician fee schedule (PFS) rates and related payment policy changes. CMS is required to release the 2014 reimbursement rates to reflect current law. Absent new legislation, Medicare providers face a 24% across-the-board reduction in payments beginning January 2014. This cut is based on the sustainable growth rate (SGR) formula. Congress is, however, expected to prevent these cuts from occurring later this year.

Even more alarming to ACG were the significant cuts to upper endoscopy, including EGD, ERCP, and esophagoscopy. Estimated cuts in Medicare reimbursement for codes in these families are over 12%. ACG is working with the AGA and ASGE to explore all options available in opposing and mitigating these cuts to our membership. ACG will update membership on any new developments impacting your practice and your Medicare patients.    

ACG members should also know that potential cuts to colonoscopy may be on the horizon. This is one reason why ACG continues to urge Congress to pass the SCREEN Act (S. 608 / H.R. 1320) despite the tough political environment on Capitol Hill. This bill improves quality of care in our specialty, lowers patient barriers to life-saving colorectal cancer screening, and also strives to ensure Medicare reimbursement for colonoscopy is fair. This is a very crucial time for clinical gastroenterology and our patients. Please urge your leaders to support the SCREEN Act:   

In addition to the looming SGR cut and other cuts in GI, all Medicare providers face an additional 2% annual reimbursement cut over the next 9 years due to “sequestration.”

Highlights of the Final Physician Fee Schedule Rule:

In-office procedures: ACG and the GI societies helped thwart the proposed cap on physician office procedures. CMS decided not to finalize its proposal to adjust relative values under the Medicare PFS to effectively cap the physician practice expense (PE) payment for procedures furnished in a non-facility setting (i.e. physician office setting) at the total payment rate for the service when furnished in an ambulatory surgical center (ASC) or hospital outpatient setting. CMS had various gastroenterology-related Healthcare Common Procedure Coding System (HCPCS) codes in this proposal, including GI motility codes and alimentary tests.

Physician Quality Reporting System (PQRS): Beginning 2014, CMS will group PQRS measures into National Quality Strategy “domains” and will require Medicare providers to report PQRS measures within these various domains. The 6 National Quality Strategy (NQS) domains: Person and Caregiver-Centered Experience and Outcomes; Patient Safety; Communication and Care Coordination; Community/Population Health; Efficiency and Cost Reduction; and Effective Clinical Care.

The GI societies successfully convinced CMS to include a new PQRS measure for 2014: Screening Colonoscopy Adenoma Detection Rate Measure (“Effective Clinical Care” NQS domain). Other popular GI measures include verification of colorectal cancer screening, medication reconciliation, and colonoscopy avoidance of inappropriate use measures (average-risk patients and patients with a history of adenomatous polyps).   

Click here to view the PQRS reporting requirements and options.

Reporting Mechanism To earn the 2014 PQRS Incentive (.5%) To Avoid the 2016 Payment Cut (2%)
Qualified Clinical Data Registry:

Measures selected by the
Qualified Clinical Data

Report at least 9 measures for 50% of applicable patients covering at least 3 NQS domains.

The eligible professional must report on at least 1 outcome measure.

Report at least 3 measures covering at least 1 NQS domain.

**ACG, ASGE, and GIQuIC help secure this change from the proposed rule**

Medicare Claims Form:

Individual PQRS Measures Only (no measure groups)

Report at least 9 measures for 50% of applicable Medicare FFS patients covering at least 3 NQS domains Report at least 3 PQRS measures.
PQRS Qualified Registry:

Individual PQRS Measures; and
GPRO (practice of 2+)

Report at least 9 measures for 50% of applicable Medicare FFS patients covering at least 3 NQS domains Report at least 3 measures covering at least 1 of the NQS domains.
PQRS Qualified Registry:

PQRS Measures Groups

Report at least 1 measures group.

At least 20 patients, a majority of which must be Medicare Part B FFS patients.

Certified EHR Product:

Individual PQRS Measures; and GPRO (practice of 2+)

Report 9 measures covering at least 3 of the NQS domains. If EHR product does not contain patient data for at least 9 measures covering at least 3 domains, then report the measures for which there is Medicare patient data.

Larger group practices may also participate in PQRS using the CMS group practice option (GPRO) website as well as through the CMS-certified survey vendor.

Value-Based Payment Modifier: CMS finalized its value-based payment modifier (VBPM) for the 2014 reporting year and 2016 payment year to apply to groups of physicians with 10 or more eligible professionals. Currently, the VBPM applies to groups of physicians with 100 or more eligible professionals. CMS estimates that this policy would include in the VBPM program approximately 17,000 groups and nearly 60% of physicians by 2016. CMS also finalized its proposal that groups of physicians with between 10 and 99 eligible professionals would not be subjected to a payment cut under the VBPM if providers participate in PQRS and avoid the 2016 payment adjustment, or have at least 50% of the practice satisfactorily participate in PQRS as individuals. Other practices will be subject to a 2% VBPM payment cut (in addition to a 2% PQRS payment cut).

Click here to learn how the Medicare Value-Based Purchasing Modifier works.

Please find the 2014 Medicare physician fee schedule final regulation here:

CMS Releases Final Payment Policies for Hospital Outpatient Departments and Ambulatory Surgical Centers

CMS also released on November 27th the 2014 Medicare final rule on payment policies for hospital outpatient departments (HOPDs) and ASCs. CMS announced the agency will increase for all services in the ASC payment system by an average of 1.2%, however, facility fees for most GI procedures next year are schedule to receive a higher percentage increase in 2014. Yet, the ASC facility fee is an estimated 53% of the HOPD rate for these same GI services as CMS will continue to use the Consumer Price Index for All Urban Consumers (CPI-U) for calculating annual updates. ACG and the GI societies continue to oppose this use of the CPI-U as the index is an inappropriate update factor to gauge ASC practice costs.

As with physician payments, in addition to the looming SGR cut and other cuts in GI, all Medicare facilities face an additional 2% annual reimbursement cut over the next 9 years due to “sequestration.”

Highlights of the Final ASC/HOPD Rule:

ASC Quality Reporting Program: CMS finalized the addition of two endoscopy/polyp surveillance quality measures for the ASC Quality Reporting (ASCQR) Program for the CY 2016 payment determination and subsequent years:

  • Appropriate follow-up interval for normal colonoscopy in average risk patients; and
  • Colonoscopy interval for patients with a history of adenomatous polyps – avoidance of inappropriate use.

ACG and the GI societies opposed including these measures in the ASC Quality Reporting Program as these measures are physician-based and belong in physician quality reporting programs such as PQRS. The ASC Quality Reporting Program is designed to measure facility-related quality.

Payments for Hospital Outpatient Visits: CMS finalized its proposal to eliminate the current five levels of outpatient clinic visit HCPCS codes, and replace them with a single HCPCS code describing all clinic visits.

The new HCPCS codes and APCs for outpatient clinic visits are reflected in the following table:

Visit Type CY 2013 CY 2014
CLINIC VISIT 99201 0604 G0463 0634
99202 0605
99203 0606
99204 0607
99205 0608
99211 0604
99212 0605
99213 0605
99214 0606
99215 0607

Please find the 2014 final Medicare Hospital Outpatient Department/Ambulatory Surgical Center regulation here:

Please stay tuned for further updates. Please also share and discuss your thoughts with fellow ACG members on the ACG GI Circle. To login and share your comments, go to and sign in as a member. Once you have done so, click here and then click the orange "Visit ACG GI Circle" button to be taken to the GI Circle site. If you have not yet activated your ACG GI Circle account, please email us at

Contact Brad Conway, VP Public Policy, with any questions or for more information.

Brad Conway