This Week – July 13, 2012

This Week in Washington DC:

  1. The 2013 Medicare Fee Schedule and Outpatient Payment Rates: The Impact to Clinical Gastroenterology
  2. House of Representatives Votes to Repeal the Health Reform Law

ACG Member Resource: A Summary of the 2013 Medicare Provider Estimated Payment Rates and Related Policy Changes
On July 6, 2012, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2013 Medicare physician fee schedule (PFS) rates and related payment policy changes. CMS is required to release the proposed 2013 reimbursement rates to reflect current law. Without new legislation, Medicare providers face roughly a 30% reduction in payments beginning January 2013. This cut is based on the sustainable growth rate (SGR) formula.

CMS also released on July 6th the 2013 Medicare proposed rule on payment policies for hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs). Certain GI codes will receive an estimated 3% increase in ASC facility fee reimbursement with the HOPD setting receiving an estimated 5% increase for the same services. On average, the ASC facility fees in the GI setting are roughly 56% of the HOPD facility rate.

The final regulations are both expected in November 2012. ACG will be providing comment to these proposed rules in an effort to make the necessary changes important to clinical gastroenterology.

In addition to the looming cut in 2013, in November 2011 Congress failed to come to an agreement on reducing overall Federal Government spending tied to raising the federal debt ceiling limits during the summer of 2011. Congress was tasked to find $1.2-1.5 trillion in savings but was unable to come to an agreement. This failure triggered a “sequestration” clause, or across the board spending cuts, that includes all Medicare provider reimbursement (physician and facility fees). Beginning January 2013, all Medicare providers face an additional 2% annual reimbursement cut over the next 10 years.

Please click here for a detailed summary of the 2013 proposed regulations and impact to clinical gastroenterology. Some highlights include:

  • Beginning 2015, physicians face a 1.5% reimbursement cut for not successfully participating in PQRS and a 2% cut in 2016 and beyond. CMS proposes to use the 2013 PQRS reporting period to determine the 2015 payment adjustment.
  • In 2013, CMS proposes for the first time to allow small group practices (2-24) to participate in PQRS via claims, a registry, or qualified EHR software similar to those requirements of individual providers.
  • 2013 is the second year in which CMS will be implementing a .5% payment incentive to successful Medicare electronic prescription (eRx) providers as well as a 1.5% payment cut for those eligible Medicare providers not successfully participating in the eRx program during the first stage of the reporting period (January – June). To qualify as a “successful eRx provider” in 2013, CMS proposes to retain the same reporting requirements and specifications as in 2012.
  • CMS once again stated that the agency will use 2013 as the reporting year to calculate the forthcoming 2015 value-based purchasing payment modifier. CMS stated that beginning 2015 the value-based payment modifier will apply to all group practices of 25 or more physicians. For those groups that have successfully reported PQRS data, the value-based purchasing payment modifier would be set at 0% of Medicare Part B charges. For groups of 25 or more that do not participate in the PQRS, CMS is proposing to set the value-based purchasing payment modifier at a -1%. This adjustment would be in addition to the penalty for unsuccessfully reporting PQRS measures (as noted above).

ESTIMATED 2013 FACILITY FEE RATES: ASC and HOPD Settings

CPT Code (APC Code)

2013 Estimated ASC Facility Fee

2012 ASC Facility Fee

2013 Estimated HOPD Facility Fee

2012 HOPD Facility Fee

43235 Upper GI Endoscopy, diagnosis (0141)

$351.32

$341.01

$623.62

$591.71

43239 Upper GI endoscopy, biopsy (0141)

$351.32

$314.01

$623.62

$591.71

45378 Diagnostic Colonoscopy (0143)

$389.60

$378.06

$691.58

$656.00

45385 Lesion Removal Colonoscopy (0143)

$389.60

$378.06

$691.58

$656.00

45331 Sigmoidoscopy and biopsy (0146)

$236.41

$251.00

$419.64

$435.53

G0105 Colorectal Cancer Screen; high risk patient (0158)

$345.03

$335.57

$612.46

$582.28

G0121 Colorectal Cancer Screen; average risk patient (0158)

$345.03

$335.57

$612.46

$582.28

House of Representatives Votes to Repeal Health Reform Law with Symbolic Vote
On Wednesday, July 11th, the U.S. House of Representatives voted mostly along party lines to repeal the health reform law, the Patient Protection and Affordable Care Act (now known as the ACA). Five Democrats joined the Republicans in voting to repeal the ACA in its entirety: Dan Boren (D-OK), Mike Ross (D-AR), Jim Matheson (D-UT), Mike McIntyre (D-NC), and Larry Kissell (D-NC).

This was a symbolic vote as the U.S. Senate will not take up the legislation this Congress. The House has voted over 30 times to repeal the ACA in part or in whole since January 2011. This most recent effort to repeal the ACA was in response to the U.S. Supreme Court’s decision on June 28, 2012 to uphold the ACA. Please click here for a detailed analysis of this decision and the impact to clinical gastroenterology.

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 www.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