This Week – March 2, 2018

This Week in Washington, D.C.

  • Call to Action: Urge your representatives to support the “Removing Barriers to Colorectal Cancer Screening Act” (S. 479; HR 1017)!
  • ACG Co-hosting Meeting with FDA: GREAT 5 for Pediatric Irritable Bowel Syndrome and Pediatric Functional Constipation
  • Good news for ACG members: Anthem rescinds modifier 25 payment policy
  • MACRA Tidbit for the Week: Crash course on MIPS Bonuses and Cuts

Call to Action:
Urge your representatives to support the “Removing Barriers to Colorectal Cancer Screening Act” (S. 479; HR 1017)!

In honor of the kick-off to Colorectal Cancer Awareness month, take action now and urge your legislators to support the “Removing Barriers to Colorectal Cancer Screening Act!” This legislation fixes a Medicare coverage quirk by waiving Medicare beneficiary cost-sharing when screening colonoscopies turn therapeutic. Right now, Medicare only has the authority to waive the patient coinsurance for colonoscopies that remain a “screening.”

Colorectal cancer is the second leading cause of cancer deaths in the United States, with over 50,000 Americans expected to die from colorectal cancer this year alone. While this country is making progress against colorectal cancer incidence rates and mortality, more needs to be done to increase the use of screening tests by Medicare beneficiaries.

To help make an impact, your legislators need to hear from you directly, and the ACG website makes this process quick and simple.  Use the link below to advocate your support.

Click here to take action now!

ACG Co-hosting Meeting with FDA

GREAT 5 for Pediatric Irritable Bowel Syndrome and Pediatric Functional Constipation

The ACG, American Gastroenterological Association (AGA), North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and FDA will be cosponsoring a public workshop in Silver Spring, Maryland on March 28, 2018, titled the Gastroenterology Regulatory Endpoints and the Advancement of Therapeutics, or GREAT 5.

The focus of this public workshop is Pediatric Irritable Bowel Syndrome and Pediatric Functional Constipation. The co-sponsored workshop will facilitate the ongoing dialogue among relevant parties on issues related to these pressing topics.

On-site registration will not be available.

Register here.

Click here for more information.

From ACG Practice Management Committee Chair Louis J. Wilson, MD, FACG

Good news for ACG members: Anthem rescinds modifier 25 payment policy

Anthem Blue Cross recently announced its intention to rescind their modifier 25 payment policy.  ACG thanks the various state and national medical societies who joined together and fought to overturn this policy since its introduction in November 2017. The policy was scheduled to begin March 1, 2018 and would have reduced reimbursement of evaluation and management (E/M) services billed with modifier 25 in conjunction with a minor procedure performed on the same day. This policy could have provided a basis for other payors to implement a similar policy as well.

Payment modifier 25 captures physician work done when separate E/M services are provided at the time of another E/M visit or procedural service.  According to the AMA’s 2018 CPT professional coding guidance:

“It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed.”

“[The] E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.” (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service)

Crash course on MIPS’ Bonuses and Cuts

MIPS Scoring- Target is at least 15 points

CMS set a really low bar to meet the MIPS’ target score in 2017.  For 2017 MIPS, the “target score” threshold was 3 points.  Any effort to participate would be sufficient to avoid a payment cut in 2019.

In CY 2018, CMS increased this threshold to 15 points.  This means that you must score at least 15 points to avoid a payment cut in CY 2020.  The size of your cut will depend on the amount of data you submit for CY 2018, up to a maximum cut of 5% of Medicare Part B allowable charges.

The BAD: The Cuts… sliding scale from less than 15 points to maximum percent of 5% of your Medicare Part B allowable charges.  The maximum cuts from failing to participate in MIPS are defined in MACRA:

  • 2020: -5% (based on CY 2018 reporting year)

The GOOD: The Bonuses…  sliding scale from 16 points up to the maximum bonuses also defined in MACRA: “Scaling Factor up to 3x the maximum cut to determine the positive adjustment.”

  • 2020: +5% up to +15%
  • Language from MACRA: “The Secretary may adjust the positive payment percentage by a scaling factor to maintain budget neutrality but may not exceed 3X.”

Umm… Huh?

  • “Budget Neutrality”: Bonuses must be proportional to cuts.  The total amount paid out must be equal to the total amount of penalties assessed that year for budget neutrality.

Does that mean in 2020, the maximum penalty is 5%…  but also a 5-15% bonus for successfully participating in MIPS? NO.


  • A provider could be eligible for up to a 15% bonus in 2020, but this depends on the actual maximum reimbursement cuts to other providers in that particular year.  It does not mean the successful MIPS scoring providers are assured a 5-15% bonus.
  • This suggests that as the cuts get higher, and the requirements gets fully implemented, there will be funds to provide MIPS bonuses.
  • This also suggests that as CMS “transitions” clinicians into MIPS and helps clinicians with avoiding reimbursement penalties, there is also limited funds for MIPS bonuses.

CMS estimates that there are 11,298 MIPS-eligible GI clinicians. According to these CMS estimates, 3% would receive a reimbursement cut in CY 2020, while 97% would be eligible for a bonus, or at least avoid a payment cut.  Thus, there must be a higher ratio of low-scoring providers in other specialties in order for ACG members to receive a MIPS bonus.

However, there is an opportunity to also earn the “Exceptional Performance Bonus.”  More on this later.