Whitfield L. Knapple, MD, FACG Chair, ACG National Affairs
Whitfield L. Knapple, MD, FACG
Chair, ACG National Affairs

On Wednesday, CMS released the 2017 proposed rule that includes policy and payment changes for the Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Centers (ASC).

On Thursday, CMS released the 2017 proposed rule that includes policy and payment changes for the Medicare physician fee schedule (MPFS).

ACG is reviewing both of the regulations and will update our membership on the potential impact to clinical GI.  In the meantime, here are some highlights:

Proposed 2017 Medicare HOPPS and ASC Facility Fees and Policy Changes:

  • Conversion factors: ASC Conversion Factor — Using the Consumer Price Index for all urban consumers (CPI-U), CMS proposes two conversion factors: one for ASCs meeting quality reporting requirements of 1.2 percent and one for ASCs not meeting quality reporting requirements of -0.8 percent in calendar year (CY) 2017. Ambulatory Payment Classification (APC) Adjustments — CMS is proposing some additional modifications in APCs following its reorganization of all APCs that resulted in the restructuring and consolidation of the APCs that contain GI procedures in 2016. We are currently reviewing the list of services and proposed payment rates for 2017 and will post them soon.
  • GI Facility Fees and APCs: CMS proposes to cut the base procedural codes for certain GI facility fees but to increase the reimbursement for the biopsy/therapeutic services within the same code family. CMS proposes to move the base codes into a different payment category of “APC” than their corresponding procedural plus biopsy codes for some of the procedures.  ACG and the GI societies will question this inconsistency in policy.
  • “Off-Campus” Hospital Department Payment Changes: Congress passed a provision in 2015 that requires that certain items and services furnished in certain off-campus provider-based departments (PBDs) not be considered for OPPS facility payment and those items and services will instead be paid under the Medicare physician fee schedule beginning January 1, 2017. Physicians furnishing these services would be paid based on the professional claim and would be paid at the non-facility MPFS rate or at the ASC facility rate if the hospital enrolls this PBD as an ASC.  CMS says it will continue to explore operational changes that would allow an off-campus PBD to bill Medicare under the MPFS.
    • If an excepted off-campus PBD furnished and billed for any designated services outlined in the rule prior to November 2, 2015, such clinical family of services would be exempt and would be eligible to receive payment under the OPPS.
    • CMS proposes that the off-campus PBD must be located at or within the distance of 250 yards from a remote location of a hospital facility.
    • Impacted GI services will include the following APCs: 5301-03, 5311-13, 5331, and 5341
    • CMS estimates that this policy change will reduce net OPPS payments by $500 million in CY 2017 and increase payment to physicians under the MPFS by $170 million in CY 2017.
  • Meaningful Use Changes for Returning Participants (CY 2016 Reporting year): CMS proposes to change the Meaningful Use reporting period in 2016 for returning participants from the full CY 2016 to any continuous 90-day period within CY 2016. This includes both physicians and hospitals.   It means all eligible providers may attest to Meaningful Use for an EHR reporting period of any continuous 90-day period from January 1, 2016 through December 31, 2016.  This impacts your 2018 reimbursement.
  • Meaningful Use Hardship for New Participants (CY 2018 Payment Year): CMS is proposing to allow all eligible professionals (both individual and hospitals) to apply for a significant hardship exception from the 2018 payment adjustment.  CMS is limiting this proposal only to eligible providers who have not successfully demonstrated Meaningful Use in a prior year, but intend to attest to Meaningful Use for the 2017 reporting year (when MIPS starts).  Providers would report this hardship by October 1, 2017 to avoid the 2018 payment adjustment.
  • Reduced Meaningful Use Thresholds and Measures for Hospitals: CMS is proposing to eliminate the Clinical Decision Support (CDS) and Computerized Provider Order Entry (CPOE) objectives and measures for eligible hospitals attesting under the Medicare EHR Incentive Program for Modified Stage 2 and Stage 3 for 2017 and subsequent years. CMS also proposes to reduce the thresholds of a subset of the remaining objectives and measures in Modified Stage 2 for 2017 and in Stage 3 for 2017 and 2018 for eligible hospitals.

ACG Note on this Meaningful Use Proposal:  While ACG appreciates CMS for reducing reporting burdens associated with CY 2016 Meaningful Use (moving to a 90 day reporting period), participating in this program in 2016 still creates a practice management conundrum that ACG has noted recently.

Proposed 2017 Medicare MPFS Policy Changes:

  • MPFS Conversion Factor: CMS estimates the CY 2017 PFS conversion factor to be 35.7751.  This is down from CY 2016 conversion factor of 35.8043.
  • Moderate Sedation: CMS proposed to remove the “moderate sedation” component from the payment for more than 100 GI endoscopic procedures, and all other codes where moderate sedation is considered inherent to the procedure. This move effectively reduces the physician work value by .10 RVUs for GI services but .25 RVUs for all other specialties.

For more on this issue, please read Dr. Robert B. Cameron’s blog.

  • Better Valuation for E&M and Cognitive Services: CMS believes that the physician work for these services are undervalued and that current service codes fail to capture the range and intensity of nonprocedural physician activities (E&M services) and the “cognitive” work of certain specialties. Among various CMS proposals on these issues include: improved payment for cognition and functional assessment and care planning, payment for complex chronic care management service, payment for non-face-to-face Prolonged E&M services by the physician (or other billing practitioner) that are currently bundled, and increase payment rates for face-to-face prolonged E/M services by the physician (or other billing practitioner).

ACG Note:  ACG has been active on this issue with a focus on IBD.  In the April issue of Gastroenterology & Hepatology, Seymour Katz, MD, MACG and Gil Y. Melmed, MD call into question the Resource-Based Relative Value Scale (RBRVS) physician compensation model for cognitive services.  “The present RVU metric for compensating physicians is flawed,” write the authors.

  • Proposed Work Value RVU for TIF (CPT Code 43210): Esophagogastric Fundoplasty Trans-Oral Approach. Many stakeholders recommended a work RVU of 9.00 for this service, however, CMS proposes to continue valuing the physician work RVU at 7.75 for CY 2017.
  • Anesthesia Services Furnished in Conjunction with Lower GI Procedures (CPT codes 00740 and 00810): CPT codes 00740 and 00810 are used for anesthesia furnished in conjunction with lower gastrointestinal (GI) procedures. In the CY 2016 PFS proposed rule, CMS identified these codes as potentially misvalued and sought public comments regarding valuation for these services. CMS proposes not to make changes for CY 2017, but continues to believe that these services are potentially misvalued, and seeks input from interested stakeholders and specialty societies.
  • Proposed “misvalued” services for review: CMS is requesting a review on the appropriate endoscopic equipment and supplies that are typically provided in all endoscopic procedures.  CMS has concerns about potential inconsistencies with the inputs and the prices related to endoscopic procedures in the direct practice expense (PE) database.  CMS also believes that reviewing the procedure codes typically billed with “an E/M with Modifier 25” as potentially misvalued may be one avenue to improve valuation of these services.  These services include: CPT Code 45300 (Diagnostic examination of rectum and large bowel using an endoscope) and CPT Code 46600 (Diagnostic examination of the anus using an endoscope).

ACG Note: ACG is monitoring the following issue as it may have future implication for GI:   CMS proposes to exercise its regulatory authority to require all practitioners who furnish a 10- or 90-day global service to submit a claim(s) providing information on all services furnished within the relevant global service, beginning with surgical or procedural services furnished on or after January 1, 2017.  CMS is proposing to require participation by practitioners selected for the broad-based survey through which we are proposing to gather additional data needed to value surgical services, such as the clinical labor and equipment involved that cannot be efficiently collected on claim.  CMS also has the authority to withhold up to 5% of payments for not participating in surveys, but is not proposing to use this authority at this time.


Whitfield L. Knapple, MD, FACG

Chair, ACG National Affairs Committee