This Week – November 11, 2011

This Week in Washington DC:

  • Final Rule on 2012 Medicare Physician Fee Schedule and Related Policy Changes:  How does this impact the GI clinician?
  • CMS Releases Final Rule on 2012 Medicare HOPD and ASC Reimbursement and Related Policy Changes: How does this impact your practice?
  • ACG Visits Capitol Hill & Capitol Hill Visits ACG
  • ACG & FDA Hold Joint Workshop on Inflammatory Bowel Disease

Medicare Providers face a 27 Percent Medicare Reimbursement Cut absent Congressional Intervention

The Centers for Medicare and Medicaid Services (CMS) on November 1 released its final rule on 2012 Medicare physician fee schedule (PFS) rates and related payment policies.  CMS is required to release its final 2012 reimbursement rate to reflect current law. Without new legislation, Medicare providers face 27.4 percent across-the-board reduction in payments beginning January 2012.  This is less than the 29 percent cut announced in July as the Medicare cost growth is lower than previously estimated.  This cut is based on the sustainable growth rate (SGR) formula that has required a reduction in Medicare reimbursement eleven times since its enactment.  Last year alone, Congress passed three bills to avert projected Medicare payment cuts, followed by two additional bills to increase Medicare payments from June 2010 to December 2011.  As ACG members are well aware, each time Congress intervenes to avert scheduled payment cuts, the cuts get carried over to the following year.  While ACG anticipates Congress will pass a temporary fix to avert this drastic cut, the final rule further demonstrates the need to eliminate SGR formula and enact true Medicare payment reform.

While ACG will continue to advocate for SGR reform, ACG will also oppose any proposal to offset SGR formula reform with further cuts to specialty reimbursement.  Please click here to view ACG’s letter to Congressional committee leaders voicing its opposition to the Medicare Payment Advisory Committee’s (MedPAC) proposal to cut specialty reimbursement:

ACG letter to committee chairs

Other payment policies in the final regulation are pursuant to the health reform law, the Patient Protection and Affordable Care Act passed in March 2010 (now known as the Affordable Care Act or “ACA”).

The 2012 Final Medicare Physician Fee Schedule Rule

Physician Quality Reporting System (PQRS).  In 2012, providers successfully reporting PQRS measures via claims, a qualified registry, or through a qualified electronic health record (EHR) are eligible to receive an additional bonus of .5 percent of all Medicare Part B fee for service charges.  The GI clinician may report on any PQRS measure.  The most popular measures for gastroenterology include:

  • Treatment and management for hepatitis C;
  • Colorectal cancer screening; (this is not an endoscopy measure but a verification of screening);
  • Health information technology and adoption/use;
  • Preventive care and screening: Body mass index screening and follow-up;
  • Documentation and verification of current medications in the medical record;
  • Treatment and management of hepatitis C (vaccinations);
  • Endoscopy and polyp surveillance/surveillance colonoscopy interval in patients with history of adenomatous polyps;
  • New Measure for 2012: Barrett’s Esophagus (pathology measure);
  • New Measure Group for 2012: Assessment, screening, and treatment management for Inflammatory Bowel Disease (IBD).

Medicare ePrescribing Incentive (eRx) Program. CY 2012 marks the first year in which CMS will be providing a 1 percent payment incentive to “successful ERx providers” as well as a 1 percent payment cut for those eligible Medicare providers not participating in the eRx program in the 2011 reporting period.  To qualify as a “successful eRx provider” in 2013, CMS retains the same reporting requirements and specifications for CY 2012 as the agency had in the 2011 reporting period.  To avoid the 2013 payment penalty, however, CMS will eliminate the requirement that the eRx measure be reported only on Medicare claims forms for certain dominator codes.  This change will help the GI clinician as the current set of denominator codes limit the opportunity for the GI clinician to meet the e-prescribing requirements.  CMS also will retain “hardship exemption” codes in certain circumstances.

Medicare EHR “meaningful use” Incentive Program.  For eligible Medicare providers participating in the “meaningful use” of health information technology incentive program, CMS will continue allowing participants to “attest” to quality measurers as opposed to reporting clinical quality measure electronically.

Review of “Misvalued” Codes.  CMS is expanding its efforts to review the payment accuracy of certain codes.  In this final regulation, CMS focuses on codes billed by physicians in certain specialties with high Medicare physician fee schedule expenditures.  CMS believes these codes may be overvalued.  Among the codes on this list impacting gastroenterology: 45378 (Diagnostic Colonoscopy) and 43235 (Upper GI Endoscopy, diagnosis).

CMS Releases Final Payment Policies in the HOPD and ASC Settings

CMS also released on November 1 the 2012 Medicare final rule on payment policies for hospital outpatient departments (HOPD) and ambulatory surgical centers (ASCs).  This rule provides for an average 1.9 percent increase in payment rates in the HOPD setting and a 1.6 percent positive update for ASCs in 2012.  ACG is currently reviewing the final regulation to further educate membership, however, facility fees in 2012 for certain GI procedures will be higher than the average 2012 rates in both the HOPD and ASC setting.  This is due to CMS’s decision to increase the ambulatory payment classification (APC) weights for certain GI procedures.

2012 Medicare Outpatient Prospective Payment System (OPPS) Final Rule


43235 Upper GI Endoscopy, diagnosis $341.01 $344.10 $591.71 $611.73
45331 Sigmoidoscopy & biopsy $251.00 $224.64 $435.53 $399.36
45378 Diagnostic Colonoscopy $378.06 $361.93 $656.00 $643.41
45380 Colonoscopy & biopsy $378.06 $361.93 $656.00 $643.41
45383 Lesion Removal Colonoscopy $378.06 $361.93 $656.00 $643.41
G0105 Colorectal Cancer Screen; High Risk $335.57 $320.57 $582.28 $569.89
G0121 Colorectal Cancer Screen; Avg. Risk $335.57 $320.57 $582.28 $569.89

** This chart compares the CMS facility fee addenda data for the final 2011 rule vs. the final 2012 rule.  The reason for the higher than average increase in facility fees as stated in the 2012 final rule are due to higher ambulatory payment classification (APC) weights.

The final rule establishes a quality reporting program for ASCs beginning in October 2012 and adopts five quality measures that will used for the 2014 payment determination.  For the 2014 payment determination, CMS will create quality data codes (QDCs) in order for ASC to report each quality measure via Medicare fee for service claims forms. These measures include:

  • Patient Burns (NQF measure #0263)
  • Patient Falls (NQF measure  #0266)
  • Wrong Site, Side, Procedure, Implant (NQF measure #0267)
  • Hospital Transfer Admission (NQF measure #0265)
  • Prophylactic IV Antibiotic Timing (NQF measure #0264)

This rule also adds two additional measures beginning 2013 for the 2015 and 2016 payment determinations.  This includes use of a safe surgery checklist and volume data for certain high-volume ASC surgical procedures (all patients).  This list includes many codes related to gastroenterology such as colorectal cancer screening and HCPCS codes 40000-49999, among others.

The rule also makes changes to the Hospital Value-Based Purchasing initiative beginning 2012.  CMS added three quality reporting measures for the 2014 and 2015 HOPD payment determinations, including requirements that HOPDs collect and submit patient volume data for the following GI procedures: colorectal cancer screening and codes 40000-49999, among others.

ACG Members Visit Capitol Hill & Capitol Hill Visits the ACG Meeting 

On Tuesday November 1, ACG members participated in an “Afternoon on Capitol Hill” event as part of the 2011 ACG Annual Scientific Meeting.  This event, sponsored by the ACG National Affairs Committee, allowed membership to take advantage of the ACG annual meeting’s Washington DC location and advocate on behalf of clinical gastroenterology.  ACG members urged their representatives to cosponsor the SCREEN Act (HR 3198) and conveyed ACG’s opposition to the Medicare Payment Advisory Commission’s (MedPAC) misguided proposal to cut specialty reimbursement as the offset to pay for SGR reform.  Participants also received an insider legislative briefing from congressional staff, including staff representing the offices of Rep. Joe Wilson (R-SC) and Sen. Lindsey Graham (R-SC).  Attendees also received a tutorial on effective strategies when meeting with members of Congress and congressional staff.

ACG thanks those who participated as well as Marylou Stinson from the South Carolina State GI Society for her assistance in organizing this successful event.  ACG members’ grassroots support and willingness to visit legislators continue to be ACG’s most effective advocacy tool.

Also on November 1 ACG meeting attendees also received the “inside scoop” on Capitol Hill from Rep. Bill Cassidy MD FACG (R-LA).  Dr. Cassidy visited the ACG Annual Meeting Exhibit Hall and provided an update on the current issues before Congress.  Dr. Cassidy also stressed to ACG members the importance of physician involvement in the political process.  ACG hopes you found this event informative and thanks those who attended to show support for one of our own.

ACG Holds Joint Workshop with FDA

On Monday, October 31st, ACG and the U.S. Food & Drug Administration (FDA) held a joint-workshop entitled “Feasibility of Mucosal Healing as a Clinically Significant Endpoint of Inflammatory Bowel Disease (IBD) Clinical Trials.”  The workshop was co-moderated by Stephen Hanauer, MD FACG and the FDA’s Zana Marks, MD MHP.  The panel reviewed and discussed four questions relating to the importance of mucosal healing as primary or meaningful endpoints in IBD.   Panel members also included: David Rubin, MD FACG, William Sandborn, MD FACG, Bruce Sands MD FACG, Brian Feagan, MD FACG, Jean Frederic Colombel, MD, J-P Achkar, MD FACG, and Robert Fiorentino, MD (also representing the FDA on this panel).

This was a very successful workshop that allowed for an open and frank discussion with the FDA, together with audience participation.  ACG hopes to continue this close working relationship with the FDA and also host more workshops at future ACG meetings.  This event was sponsored by ACG’s FDA Related Matters Committee.

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