Late Wednesday, July 8, CMS released the 2016 Medicare Physician Fee Schedule (MPFS) proposed rule which, if finalized, would drastically cut reimbursement rates for colonoscopy and other lower GI endoscopy procedures.

AGA, ACG and ASGE will fight these cuts. We are scheduled to meet with CMS leadership this month and are exploring every means to mitigate these cuts before they are finalized. Cuts of this magnitude could compromise the nation’s public health efforts to reduce colorectal cancer.

The proposed physician work values for the colonoscopy family are cut up to 19 percent. Errors in the data files posted by CMS prevent us from estimating the total impact at this time; we will provide this information as soon as possible.

Review the proposed rule.

The rates proposed by CMS for the colonoscopy code family are not data-driven. Further, the methodology used to determine physician work and intensity for these services is severely flawed.

These proposed rates represent significant cuts in reimbursement for life-saving colonoscopy procedures.

What’s Next?

The societies will conduct thorough reviews of the MPFS and Hospital Outpatient Prospective System/ Ambulatory Surgical Center Payment System proposed rules and will provide a detailed analysis. All comments to the MPFS proposed rule are due on Sept. 8, and the rates will be finalized in November and take effect Jan. 1, 2016.

Please watch your email for alerts from the GI societies on how you can express your concerns to CMS about the impact these proposed reimbursement cuts will have on your patients and practices.

Proposed Colonoscopy Reimbursement Rates for 2016

Top Lower GI Endoscopy Procedures

The following is a summary of the proposed rate changes for the top lower GI endoscopy procedures.  These rates are considered proposed, meaning that CMS can choose to revise the values before they are finalized for 2016.

CPT Code Short Descriptor 2015 Physician Work RVU CMS 2016 Proposed Physician Work RVU RVU % Change
45380 Colonoscopy with biopsy 4.43 3.59 -19%
45385 Colonoscopy with snare polypectomy 5.30 4.67 -12%
45378 Colonoscopy 3.69 3.29 -11%
G0105 Colorectal cancer screen, high risk 3.36 3.29 -2%
G0121 Colorectal cancer screen, low risk 3.36 3.29 -2%
45384 Colonoscopy with hot biopsy 4.69 4.17 -11%
45381 Colonoscopy with submucosal injection 4.19 3.59 -14%
45388* Colonoscopy, flexible with ablation 5.86 4.98 -15%
45331 Flexible sigmoidoscopy with biopsy 1.15 1.07 -7%
45330 Flexible sigmoidoscopy 0.96 0.77 -20%
45382 Colonoscopy with control of bleeding 5.68 4.76 -16%
*45383 was deleted in CPT 2015 and replaced by 45388. CMS created G6024, the equivalent of 45383, for CY 2015.


The Three GI Societies Have Acted Together on your Behalf

For the past two years, our three societies have advocated with CMS for fairness, transparency and accuracy in rate-setting for GI physician services. Our societies led a multi-society campaign, which included a request from members of Congress and several leadership meetings with CMS, to improve transparency in Medicare rate-setting, including for lower GI services.

Our campaign was a success, resulting a one-year delay in the valuation of lower GI endoscopy procedures and revisions to the way CMS implements changes to reimbursement by allowing more transparency in its rate-setting process and an opportunity for the public to review and comment on any changes before new rates can be implemented. Starting in 2017, public comments will be considered for the vast majority of payment changes before they take effect, however this new process was applied to GI services in the CY 2016 proposed rule. While our societies applauded CMS’ actions at the time, our underlying concerns persisted, namely, whether CMS would: 1) apply the same flawed methodology for revaluing lower GI endoscopy services as was used for the upper GI endoscopy codes; and 2) establish new lower GI endoscopy valuations before CMS finalizes valuations for moderate sedation.

How These Cuts Happened: Misvalued Code Initiative & the RUC

In the 2012 MPFS Final Rule, CMS identified colonoscopy, EGD and other GI endoscopy procedures as being potentially misvalued through the Misvalued Code Initiative.  Since that time, the GI and surgical societies surveyed and provided recommendations to the AMA RUC panel for more than 100 GI services in eight code families.

Unfortunately for the colonoscopy code family — our highest volume code family — the RUC failed to follow its own processes during the code family’s review in January 2014.  Compounding this error, CMS failed to base its valuation on real-world data collected by the three GI societies. Instead of relying on the robust and representative survey data that showed physician time and intensity for colonoscopy had not changed, the RUC panel used time and intensity data from another specialty to determine the value of colonoscopy services,  resulting in a recommendation to CMS not supported by the survey data considered to be  gold-standard by the RUC and CMS. During the RUC’s review of the colonoscopy codes and throughout last year, our societies voiced to CMS and the RUC our opposition to the process used to value colonoscopy.  We do not believe CMS considered the data in making its determination.

For more information, please see the Q&A prepared by the three societies.