3 Major Physician Fee Schedule Changes That Will Impact Gastroenterology

Warning: CMS may cut your colonoscopy and EGD pay

Get ready for some critical colonoscopies coding changes. The Centers for Medicare & Medicaid Services (CMS) recently released the proposed 2019 Medicare Physician Fee Schedule (PFS), which contains a few significant surprises. Find out if the changes will benefit or harm your reimbursement for gastroenterology services.

Watch out: Thanks to 2019 ICD-10 and CPT® coding updates, you have plenty of coding learning to do, but the proposed Medicare PFS is poised to throw you an extra curveball involving a potential overhaul of the Evaluation and Management (E/M) coding system, according to gastroenterology coding expert Jill Young in her 2019 Coding Updates Virtual Boot Camp for Gastroenterology.

The proposed PFS contains the following three changes that will have a particular impact on gastroenterology:

Beware of Significant E/M Changes

Perhaps the most significant proposed change is a whole new reimbursement methodology for E/M services, according to a recent blog posting by the American College of Gastroenterology (ACG). CMS proposes to combine E/M Level 2 through 5 into a single flat rate, with the only differentiation being new versus established patients.

How it works: So for a Level 1 E/M visit, you would receive a $44 payment for a new patient (99201) or $24 for an established patient (99211). For E/M Level 2 through 5 visits, you would receive $135 for a new patient (99202-99205) or $93 for an established patient (99212-99215).

Advantage? The aim is to save physicians time by minimizing documentation and administrative burdens.

In a recently released Fact Sheet, CMS explained that it proposes to allow practitioners to:

  • Choose to document E/M visits using medical decision-making or time instead of applying the current 1995 or 1997 guidelines;
  • Use time as the governing factor in selecting the visit level and documenting the E/M visit, regardless of whether counseling or care coordination dominate the visit;
  • Focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting information; and
  • Simply review and verify certain information in the medical record that ancillary staff or the patient have entered, instead of re-entering it.

Bright spot? CMS would also create new codes to provide add-on payments for office visits, according to an American Academy of Family Physicians (AAFP) summary. The add-on payment would be $9 for specialties such as gastroenterology and $5 for primary care physicians.

Disadvantage: Unfortunately, CMS proposes to implement a 50-percent multiple procedure payment reduction to the lower paid of the two services when you report an E/M service and a procedure on the same date.

Brace for Possible Pay Cut for 43239 & 45385

More bad news: Under the Misvalued Code Initiative, CMS received public nomination of several high-volume codes. The nominations included CPT® codes 45385Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique and 43239Esophagogastroduodenoscopy, flexible, transoral; biopsy; single or multiple.

Submitters have suggested that CPT® codes 45385 and 43239 are “overvalued” in terms of work Relative Value Units (RVUs). Now, CMS will work with the ACG, American Gastroenterological Association (AGA), and American Society for Gastrointestinal Endoscopy (ASGE) to determine whether these GI codes are properly valued.

Watch for Removal of Colonoscopy Quality Category

Finally, the proposed rule includes a variety of changes to the Quality Payment Program (QPP), including the Merit-Based Incentive Payment System (MIPS). Among the revisions is the removal of 34 quality measures, including QPP185 (Colonoscopy Interval for Patients with a History of Adenomatous Polyps — Avoidance of Inappropriate Use), ACG reported.

CMS also proposes adding a new cost measure for screening/surveillance colonoscopy to the performance category. This would begin with the 2019 MIPS performance period.

Mark your calendar: After CMS finalizes the PFS proposed rule, the changes will be effective Jan. 1, 2019.

Key takeaway: Keep your eyes peeled for updates on the Medicare PFS rule, and make sure you’re preparing for the ICD-10 and CPT® code updates. You should know not only how to report the new codes properly—including for gastroenterology E/M service—but also what documentation you’ll need to support your claims, Young stresses.

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