This Week – January 3, 2013

This Week in Washington DC:

  1. Congress Passes Legislation to Avert 2013 SGR Payment Cuts
  2. ACG Submits Comment to CMS on the 2013 Medicare Physician Fee Schedule: ACG is also seeking your help!

Congress Delays SGR Cuts Until January 2014
On January 1, 2013 the House of Representatives passed legislation averting the “fiscal cliff” of expiring federal income tax rates and other scheduled federal spending cuts, including Medicare reimbursement. The Senate passed the same bill in the early hours of January 1, 2013 after Senate Minority Leader Mitch McConnell (R-KY) and Vice President Joseph Biden came to an agreement over the holiday weekend. This legislation blocks a scheduled 27% reduction in the Medicare reimbursement rate for physician services that was set to occur on January 1, 2013 and maintains the current reimbursement rate through December 31, 2013. According to the Congressional Budget Office (CBO), the cost of the 1-year extension is $25.2 billion over 10 years.

The bill also directed the Health and Human Services Department (HHS) to work with interested parties to collaborate with clinical data registries and implement quality improvements for services paid under Medicare. ACG has long-advocated that if Congress chooses to move toward a more value-based reimbursement model in Medicare, then it should incorporate participation in registries such as the GI Quality Improvement Consortium (GIQuIC) into any future reimbursement model. This way, specialty societies such as ACG have a seat at the table in defining and demonstrating “quality of care,” which may help ensure ACG members are fairly and accurately reimbursed for these services. Please contact ACG to learn more about how you can satisfy 2012 and 2013 Medicare quality reporting requirements by participating in GIQuIC.

The legislation also extends the Medicare Work Geographic Adjustment through 2013. As background, the Medicare fee schedule is adjusted to reflect the differences in the cost of providing services in different geographic areas. This adjustment is based on 3 factors: physician work, practice expense, and the cost of medical malpractice insurance. Medicare identifies 89 unique geographic areas. CBO estimates that these provisions would cost roughly $500 million over 10 years.

SEQUESTRATION: The bill also delays for 2 months the automatic spending reductions scheduled to take effect January 1, 2013 due to “sequestration.” As part of this agreement, Medicare physicians and facilities are scheduled to receive annual 2% reimbursement cuts over the next 10 years. ACG members may still experience cuts beginning March 2013 if Congress fails to pass legislation in the upcoming weeks.   

What is the Impact to Certain GI Services and Procedures?

CPT Code (APC Code)

2013 Medicare Physician Payment**

 

2013
ASC Facility Fee**

2012
ASC Facility Fee

2013 HOPD Facility Fee**

2012 HOPD Facility Fee

43235 Upper GI Endoscopy, diagnosis (0141)

$148.06

 

$349.83

$341.01

$623.45

$591.71

43239 Upper GI endoscopy, biopsy (0141)

$174.61

 

$349.83

$341.01

$623.45

$591.71

43248 Upper GI Endoscopy, guide wire (0141)

$191.63

 

$349.83

$341.11

$926.78

$591.21

43249 Esoph endoscopy, dilation (0419)

$176.66

 

$520.05

$510.84

$926.78

$885.37

43269 Endo cholangiopancreatograph (0384)

$481.29

 

$1,187.92

$1,179.60

$2,177.02

$2,044.46

45331 Sigmoidoscopy and biopsy (0146)

$77.27

 

$235.85

$251.00

$420.32

$435.53

45378 Diagnostic Colonoscopy (0143)

$220.56

 

$387.92

$378.06

$691.32

$656.00

45385 Lesion Removal Colonoscopy (0143)

$312.81

 

$387.92

$378.06

$691.32

$656.00

46221 Ligation of hemorrhoids(s) (0148)

$189.59

 

$137.50

$123.60

$439.35

$389.02

91110-26 GI Tract capsule endoscopy (0142)

$195.38

 

NA

NA

NA

NA

91110 GI Tract capsule endoscopy (0142)

NA

 

NA

NA

$750.68

$723.63

G0105 Colorectal Cancer Screen; high risk patient (0158)

$220.56

 

$343.28

$335.57

$611.77

$582.28

G0121 Colorectal Cancer Screen; average risk patient (0158)

$220.56

 

$343.28

$335.57

$611.77

$582.28

** All 2013 Medicare reimbursement may be cut 2% beginning March 2013 due to automatic spending cuts or “sequestration.”

ACG will continue to advocate on your behalf and update membership as Congress addresses “sequestration” and other legislation impacting ACG members. 

ACG Provides Comment on Final 2013 Medicare Payment Regulations
On Monday, December 31, 2012, ACG submitted comments to the final 2013 Medicare physician fee schedule rule. The Centers for Medicare and Medicaid Services (CMS) released this rule on November 1, 2012. ACG’s comments covered the significant cut in reimbursement to the technical component of pathology code ‘88305’ and recommendations to improve the Medicare Physician Compare website.

Please click here to read ACG’s comment letter.

ACG Seeks Your Input: CMS decided to cut the technical component to the pathology code ‘88305’ by 52% beginning this year. This change may have a significant impact on those GI practices with pathology labs. Due to a slight increase in the professional services component of the code, the global payment for 88305 will be cut by 33%. CMS’ decision was based in part on the assumption that labs use 2 slide-blocks on average each time this code is reported on a Medicare claims form but also sought comment from interested stakeholders. ACG reached out to certain practices with GI pathology labs who confirmed that this assumption may be inaccurate for many endoscopic procedures. ACG presented this feedback in the comment letter and cited various clinical guidelines as well as other research in IBD, Barrett’s esophagus, eosinophilic esophagitis (EoE), and colorectal cancer prevention to further demonstrate that CMS should reverse this payment cut in a future rulemaking. However, ACG needs further data from impacted GI practices as we continue to work with CMS.

Please contact ACG if your pathology lab routinely requires more than 2 slide-blocks each time 88305 TC is reported on a Medicare claims form.             

Please click here to access the final regulation on the 2013 Medicare physician fee schedule and other policy changes.

ACG will continue to work with CMS on behalf of clinical gastroenterology to help ensure fair and accurate Medicare reimbursement. 

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 gi.org 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 acgcirclefeedback@within3.com.

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

Brad Conway
bconway@gi.org