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Brad Conway, ACG Vice President of Public Policy
Brad Conway, ACG Vice President of Public Policy

The Centers for Medicare and Medicaid Services (CMS) released the proposed rule July 2 that includes policy and payment changes for the Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Centers (ASC) for calendar year (CY) 2016. These changes, if finalized, would be effective January 1, 2016.

Read the CMS Fact Sheet

The American College of Gastroenterology (ACG), the American Society for Gastrointestinal Endoscopy (ASGE), and the American Gastroenterological Association (AGA) are further analyzing the proposed rule to understand the impact on gastroenterology services. We are encouraged that CMS adopted the GI societies’ recommended new Ambulatory Payment Classifications (APC) for certain GI services.

However, we are committed to fight the small cut in facility fees for the colonoscopy family of codes.

In this proposed rule, CMS describes the recommended changes to the amounts and factors used to determine the payment rates for Medicare services paid under the HOPPS, outlines its reconfiguration of several Ambulatory Payment Classifications (APCs) and modifies those paid under the ASC payment system. In addition, this proposed rule updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program.

ASC Conversion Factor – Using the Consumer Price Index for all urban consumers (CPI-U), CMS proposes to increase ASC payment rates by 1.1 percent in CY 2016. For GI services, CMS proposes to increase facility fees for common procedures such as EGD, ERCP, and Esophagoscopy by 4 percent on average. However, ASC facility fees are scheduled to decrease by 2 percent for nearly all colonoscopy codes. Also, as required by law, ASCs are subject to a 2 percent reduction in their annual payment if they fail to meet the requirements of the ASCQR Program. The calendar year (CY) 2018 ASCQR Program measure set includes 12 measures — 11 required and one voluntary. CMS is not proposing to add any new measures to the program in this proposed rule.

Restructuring APCs – CMS is proposing a major reorganization of all APCs resulting in the restructuring and consolidation of the APCs that contain GI procedures from 23 APCs to 13 APCs. In the proposed rule, CMS states the proposed APC groupings would more accurately accommodate and align new services within clinical APCs with similar resource costs.

Upon initial review of the restructured APCs, reimbursement for EGD codes would increase 3 percent, on average. The colonoscopy codes would be decreased approximately 3 percent, with the exception of the stent code, which would increase 359 percent, thanks to the movement of the stent codes to a new APC.

GI Stent Procedures – For the past year, the GI societies have advocated for the APC reassignment of four lower endoscopy stent procedures. CMS is proposing to accept our recommendation and plans to move CPT codes 44384 (Ileoscopy with stent), 44402 (C-stoma with stent), 45347 (Flex sig with stent) and 45389 (Colonoscopy with stent) to APC 5331 (Complex GI Procedures), resulting in payment increases of 359 percent for these services.

CMS will accept comments on the proposed rule until August 31, 2015, and will respond to comments in a final rule to be issued on or around November 1, 2015. The proposed rule will appear in the July 8, 2015, Federal Register and can be downloaded at:

Watch your email for more GI reimbursement news. We expect the proposed Medicare Physician Fee Schedule to be released shortly, including new rates for colonoscopy and other lower GI endoscopy procedures.

Brad Conway, ACG Vice President of Public Policy