This Week – September 7, 2012

This Week in Washington DC:

  1. ACG Submits Comment to the Proposed 2013 Medicare Physician Fee Schedule and Outpatient Facility Payment Rates

CMS to Move Forward with Health Reform Law Policy Changes While Medicare Payment Cuts Loom
On Tuesday, September 4th, ACG joined the AGA and ASGE in submitting comments to the 2013 proposed regulation on the Medicare Physician Fee Schedule (PFS) and other policy changes. This rule was published in the Federal Register on July 30, 2012.

CMS is required to release the proposed 2013 reimbursement rates to reflect current law. Without new legislation, Medicare providers face a 27% cut in payments beginning January 2013. This cut is based on the sustainable growth rate (SGR) formula.

As if this unwarranted reimbursement cut to ACG members is not enough, Medicare providers are also scheduled to receive annual 2% Medicare reimbursement cuts over the next 10 years due to “sequestration.” When Congress raised the federal debt ceiling limit in the summer of 2011, a group of twelve members of Congress were tasked to find $1.2-1.5 trillion in federal savings by November 2011. However, this bipartisan deficit reduction panel failed to agree on any proposal so the default agreement called for “sequestration,” or across-the-board spending cuts beginning in January 2013. This includes annual Medicare provider reimbursement cuts up to 2% for the next 10 years. ACG is monitoring the current budget and spending authorization debate on Capitol Hill that would eliminate this “sequestration” agreement, thereby, eliminating these cuts to Medicare providers.

It remains unclear whether Congress will repeal “sequestration” and when Congress will address the looming Medicare provider cuts due to the SGR formula. What is clear, however, is that Congress is not expected to address either issue until after the November 2012 elections.

Physician Quality Reporting System (PQRS):
Beginning 2015, physicians face a 1.5% reimbursement cut for not successfully participating in PQRS. This cut increases to 2% cut in 2016 and beyond. CMS proposes to use the 2013 PQRS reporting period to determine this 2015 payment adjustment.  

CMS proposes to add 2 new quality measures relevant to clinical GI. ACG and the ASGE were successful in getting CMS to include these measures in PQRS for 2013. They include:

  • Endoscopy and Polyp Surveillance: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients
  • Participation by a Physician or Other Clinician in a Systematic Clinical Database Registry that Includes Consensus Endorsed Quality. This means that mere participation in the GI Quality Improvement Consortium (GIQuIC) helps ACG members successfully meet PQRS reporting requirements

In 2013, providers successfully reporting PQRS quality measures via Medicare claims, a qualified registry, or through a qualified electronic health record (EHR) are eligible to receive an additional bonus of .5% of all Medicare Part B charges. CMS proposes to include 264 individual measures from which physicians must choose 3, and noted that 14 of these proposed measures are newly proposed in 2013. Providers may instead also choose to report a PQRS “Measures Group.” CMS chose to eliminate for 2013 one popular measure used by ACG members: PQRS Measure #124: Health information technology and adoption.

CMS proposes for the first time to allow small group practices to participate in PQRS group reporting option (GPRO) via claims, a registry, or qualified EHR software similar to those requirements of individual providers. Previously, larger group practices of 25 providers or more could participate in PQRS GPRO. However, group practices as small as 2 providers may participate in PQRS GPRO beginning 2013.    

The most popular measures and measures groups relevant to gastroenterology include:

  • Measure 83: Testing for Hepatitis C.
  • Measures 84- 90: Treatment and management of Hepatitis C.
  • Measure 113: Colorectal cancer screening. (This is not an endoscopy measure but a verification of screening).
  • Measure 128: Preventive care and screening; body mass index screening and follow-up.
  • Measure 130: Documentation and verification of current medications in the medical record.
  • Measures 183 and 184: Treatment and management of Hepatitis C (Hepatitis A and B vaccinations).
  • Measure 185: Endoscopy and polyp surveillance/surveillance colonoscopy interval in patients with history of adenomatous polyps.
  • New Measure for 2013: Endoscopy and Polyp Surveillance: Appropriate follow-up interval for normal colonoscopy in average risk patients (NQF Measure #0658)
  • New Measure for 2013: Participation by a physician or other clinician in a systematic clinical database registry that includes consensus endorsed quality measures (NQF Measure #0493) 
  • Measure Group: Hepatitis C
  • Measure Group: Inflammatory Bowel Disease (IBD).

The GI societies urged CMS to incorporate more specialty-specific PQRS measures such as the joint-society developed “colonoscopy” PQRS Measures Group.

Medicare E-Prescribing (eRx) Incentive Program:
2013 is the second year in which CMS will be implement a .5% payment incentive to successful 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 of stage of the reporting period (January – June). This means that ACG members could qualify for both a reimbursement cut, by failing to report eRx requirements specific to the January – June 2013 reporting period, and also the .5% bonus payment by successfully reporting eRx measures in the January – December 2013 reporting period.

To qualify as a “successful eRx provider” in 2013, CMS proposes to retain the same reporting requirements and specifications as in 2012. Please click here for further guidance on the Medicare eRx Program reporting requirements:

CMS proposes to retain the current hardship exemptions in certain circumstances as well as the following new hardship exemptions:

  • Eligible professionals or group practices who achieve “meaningful use” during certain eRx payment adjustment reporting periods; and
  • Eligible professionals or group practices who demonstrate the intent to participate in the Medicare “meaningful use” program.

In this 2013 proposed rule, CMS allows small group practices (2-24) to use the eRx GPRO web-interface. This reporting option was previously available to only larger group practices.  

CMS proposes to establish an informal review process for the eRx program. This will be modeled after the informal review process established under PQRS. The proposed informal review process would only be available for the 2013 eRx incentive payments and the 2014 eRx payment adjustment.

Physician Compare Website:
The Affordable Care Act (ACA) requires CMS to create a plan by 2013 for a “Medicare Physician Compare” website that would ultimately display individual physician performance on quality measures and other pertinent information. CMS launched this website in December 2010 and has since added information on those physicians who have successfully participated in the PQRS and Medicare eRx programs. CMS proposes for 2013 to post successful participation in the Medicare electronic health record (EHR) “meaningful use” program. CMS also proposes to post on the website by 2013 the PQRS performance rates for all group practices participating in GPRO PQRS reporting mechanism.  The GI societies recommended that CMS include on Physician Compare pertinent information that Medicare beneficiaries would find useful when searching for a physician, such as voluntary participation in various medical society-driven quality improvement initiatives or other specialty-specific quality measures.  

CMS will begin posting patient satisfaction or "experience data" by January 2014 for all group practices participating in PQRS GPRO in 2013 and the Medicare Shared Savings programs (The ACO program).  The GI societies recommended that CMS must first confirm the accuracy of the data that is currently on the Physician Compare before moving ahead with any future Physician Compare website plans. The GI societies also urged CMS to afford physicians the ability to confidentially review and challenge any “patient experience” data before it is publicly posted on the provider’s individual profile.   

CMS stated that it does not believe it will begin posting individual physicians PQRS participation rates or value-based purchasing modifier metrics before 2016.

The “Physician Compare” website:

Physician Value-Based Purchasing Payment Modifier:
The ACA requires CMS to implement a “value-based purchasing payment modifier” for certain physicians by 2015, as determined by CMS, and all physicians by 2017.

CMS once again stated that the agency will use 2013 as the reporting year to calculate the 2015 value-based purchasing payment modifier.  CMS stated that beginning 2015 the value-based payment modifier will apply to all group practices with 25 or more physicians. For those groups that have successfully reported PQRS data, the value-based purchasing modifier would be set at 0% of total Medicare Part B charges. For groups of 25 or more that do not successfully participate in the PQRS, CMS is proposing to set the value-based purchasing modifier at a -1%. This adjustment would be in addition to the penalty for unsuccessfully reporting PQRS measures.  

Those large group practices successfully reporting PQRS measures would then be offered a “quality-tiering” option. This option would allow these groups of physicians to earn an upward payment adjustment for high performance (high-quality of care tier and low-cost) performance but be at risk for a downward payment adjustment for poor performance (low-quality of care tier and high-cost). The proposed rule does not specify the upward adjustment, but notes that the maximum downward adjustment would be -1% of total Medicare Part B charges. The GI societies urged CMS to keep this “quality-tiering” approach optional for all group practices and Medicare providers.

Please click here to read the joint-society comment letter on the 2013 proposed changes to the Medicare Physician Fee Schedule.

CMS Continues to Employ Misguided Policies for ASC Payment Updates
Also on Tuesday, September 4th, ACG joined the AGA and ASGE in submitting comment to the proposed regulation on 2013 Medicare outpatient facility payments rates and related policy changes. This rule was also published in the Federal Register on July 30, 2012.

Overall, this rule provides for a 1.3% positive update for ambulatory surgical centers (ASCs) in 2013 while CMS proposes to increase 2013 hospital outpatient department (HOPD) rates by 2.1%.  Certain GI codes are estimated to receive a 3% increase in ASC facility fee reimbursement while the HOPD setting will receive an estimated 5% increase for the same services. On average, GI facility fees in the ASC setting is roughly 56% of the HOPD facility rate. This is due to CMS’s current misguided policy of annually updating ASC facility fees based upon the consumer price index for all urban consumers (CPI-U) but using the hospital market basket when updating rates in the HOPD setting. The hospital market basket is the estimated the increase in costs of providing services in the inpatient hospital setting. While ASCs may not have costs in the aggregate versus the HOPD setting, CMS must recognize that ASCs have the same types of costs when treating Medicare beneficiaries.

The GI societies urged CMS to simply be consistent and use the same inflationary update for both the ASC and HOPD settings. This will help prevent this growing divergence in facility fee rates between each setting.      

ACG members should also be aware that the Medicare reimbursement cuts under “sequestration” also apply to Medicare provider facility fees. Thus, ASC and HOPD facility fees are scheduled for an annual 2% cut over the next 10 years.

Proposed 2013 Facility Fee Rates for Certain GI Procedures:

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)





43239 Upper GI endoscopy, biopsy (0141)





45378 Diagnostic Colonoscopy (0143)





45385 Lesion Removal Colonoscopy (0143)





45331 Sigmoidoscopy and biopsy (0146)





G0105 Colorectal Cancer Screen; high risk patient (0158)





G0121 Colorectal Cancer Screen; average risk patient (0158)





ASC Quality Reporting Program:
CMS will move forward with implementing the Medicare ASC quality reporting program beginning October 2012. ASCs will report these quality measures from October to December 2012 to be eligible for a full update in 2014. The proposed measures include seven surgical and control measures and one healthcare associated infection measure that would be reported through the National Healthcare Safety Network.

CMS also requires ASCs to report two additional “structural” measures in 2013 in order to be eligible for a full ASC payment update in 2015: 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 codes 40000-49999, among others.

For the 2014 payment determination, CMS created quality data codes (QDCs) in order for ASCs to report each quality measure via Medicare fee-for-service claims forms. These measures include:

  • Patient Burns (NQF #0263)
  • Patient Falls (NQF #0266)
  • Wrong Site, Side, Procedure, Implant (NQF #0267)
  • Hospital Transfer Admission (NQF #0265)
  • Prophylactic IV Antibiotic Timing (NQF #0264)
  • Ambulatory Patient with Appropriate Method of Surgical Hair Removal (NQF #0515)
  • Prophylactic Antibiotic Selection for Surgical Patients (NQF #0268)- first or second generation Cephalosporin
  • Surgical Site Infection Rate (to be reported in 2013 but derived from ASC data in CY 2012)

For the 2015 payment determination, the additional quality measures include: verification of a “safe surgery checklist” and submission of patient volume data (all patients) for certain high volume codes.  The following codes impact gastroenterology (to be reported in 2013 but based on 2012 data):

  • Codes 40000-49999
  • G0104: CRC Screening flexible sigmoidoscopy
  • G0101: CRC Screening; high risk individual
  • G0121; CRC Screening; not high risk
  • C9716: Thermal Anal Lesions by Radiofrequency
  • C9724: Endoscopic full thickness placation in gastric cardi using EPS
  • C9725: Placement of endorectal intracavitary for high intensity brachytherapy

Please click here to prepare for the Medicare ASC Quality Reporting Program:

CMS also solicited recommendations for quality measures in the outpatient setting specifically related colonoscopy and endoscopy. In response to this request, the GI societies recommended CMS incorporate the following facility-related measures: “equipment reprocessing,” “sedation safety,” and “emergency department visit within 72 hours of ASC-discharge.”

Please click here to read the joint-society comment letter on the 2013 proposed changes to Medicare outpatient facilities.

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