This Week – July 9, 2013

This Week in Washington DC:

  1. CMS Releases Proposed 2014 Medicare Physician Fee Schedule Rates and Other Policy Changes: Total Impact to GI Remains Unclear
  2. CMS Releases Proposed 2014 Hospital Outpatient Department and Ambulatory Surgical Center Payment Rates and Policy Changes

CMS Releases Proposed Regulation on Medicare Physician Fee Schedule
On Monday, July 8, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2014 Medicare physician fee schedule (PFS) rates and related payment policy changes. The final regulation is expected in November 2013. CMS is required to release the proposed 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. However, Congress is expected to prevent these cuts from occurring later this year.

Highlights from the proposed rule:

  • CMS notes that the proposed net reimbursement impact to GI is +1%, excluding SGR.  CMS specifically mentions 43239 (upper GI endoscopy, biopsy) and provides for a 2% increase in 2014 reimbursement (excluding SGR). 
  • CMS is proposing a new measure for the physician quality reporting system (PQRS): adenoma detection rate. ACG and our sister societies (AGA and ASGE) requested that this measure be included in PQRS as this measure will help GI clinicians participate in PQRS. All Medicare participating physicians failing to successfully participate in PQRS in 2014 will receive a 2% reimbursement cut in 2016.
  • CMS is proposing a new PQRS reporting option for clinical quality data registries developed by specialty societies. ACG welcomes this news and requested CMS to streamline the Federal Government’s quality improvement efforts with those of clinical databases such as “GIQuIC.”
  • CMS is proposing to expand the list of providers eligible to write orders for a fecal occult blood test (FOBT) for colorectal cancer screening. Currently, only a physician may furnish a written order for FOBT. CMS is proposing to allow nurse specialists, nurse practitioners, and physician assistants to write orders for FOBT in 2014. 

Outstanding Issues:

It is important to note that CMS might propose further cuts to GI reimbursement for 2014. These cuts would likely come pursuant to the ongoing review of “misavlued” codes in gastroenterology. While CMS is currently not proposing reimbursement cuts, ACG is closely monitoring this issue. For example, just last year when CMS announced the 52% cut in the technical component of pathology code 88305, this announcement was part of the final regulation released in November 2012 and not in the proposed regulation released in July 2012.

ACG members should also know that potential cuts to colonoscopy may be in the horizon.  This is one reason why ACG continues to urge Congress to pass the SCREEN Act (S. 608 / H.R. 1320). This bill the 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:

http://www.capwiz.com/acg/home/

Sequestration:
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.”  Medicare providers’ reimbursement was reduced by 2% in April of this year.

Please find the 2014 Medicare physician fee schedule proposed regulation here:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1600-P.html

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

CMS also released today the 2014 Medicare proposed rule on payment policies for hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs). This rule provides for positive updates for selected GI services in 2014 yet the ASC facility fee is an estimated 53% of the HOPD rate for these same services. ACG continues to urge CMS to align ASC payment rates with the HOPD setting as the ASC setting saves the Medicare programmatic costs and provides safe and cost-effective care to Medicare beneficiaries. The final regulation for these facility payment policies is also expected in November 2013.

ACG is currently reviewing the proposed regulation and preparing comments. ACG will update membership on these proposed changes and will continue to fight for GI ASCs and other physician-owned facilities.

Sequestration:
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.” Medicare facilities’ reimbursement was reduced by 2% in April of this year.

ESTIMATED 2014 FACILITY FEE RATES: ASC and HOPD Settings (2014 rates do not include sequestration)

CPT Code (APC Code)

2014 Estimated  ASC Facility Fee

2013 ASC Facility Fee (adjusted for sequestration)

2014 Estimated HOPD Facility Fee

2013 HOPD Facility Fee (adjusted for sequestration)

43235 Upper GI Endoscopy, diagnosis (0141)

$395.32

$342.83

$740.96

$610.98

43239 Upper GI endoscopy, biopsy (0141)

$395.49

$342.83

$740.96

$610.98

45378 Diagnostic Colonoscopy (0143)

$415.51

$380.16

$778.45

$677.49

45385 Lesion Removal Colonoscopy (0143)

$415.51

$380.16

$778.45

$677.49

45331 Sigmoidoscopy and biopsy (0146)

$438.11

$231.13

$480.43

$411.91

G0105 Colorectal Cancer Screen; high risk patient (0158)

$344.85

$336.41

$646.06

$599.53

G0121 Colorectal Cancer Screen; average risk patient (0158)

$344.85

$336.41

$646.06

$599.53

Please find the 2014 Medicare facility fee schedule proposed regulation here:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/ASC-Regulations-and-Notices-Items/CMS-1601-P.html

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
301-263-9000