Nearly 450 gastroenterologists with the American Gastroenterological Association, American College of Gastroenterology and American Society of Gastrointestinal Endoscopy submitted a letter to the Centers for Medicare and Medicaid Services in response to the Medicare 2015 physician fee schedule proposed rule. Joel V. Brill, MD, FACP, AGAF, FASGE, FACG, AGA CPT/ advisor, answers questions on the GI societies' advocacy efforts.
Question: Has CMS responded to advocacy efforts made in the past?
Dr. Joel Brill: In the proposed rules CMS made a number of suggestions that followed up on what the GI societies had previously suggested to the agency. CMS addressed several of our comments regarding inappropriate placement of ERCP and stenting procedures, and upper GI endoscopic mucosal resection (EMR) into ambulatory payment classifications (APC). We made recommendations in regards to putting capsule procedures into one APC and they agreed. They also responded to our request for the esophageal BRAVO procedure and proposed that it would be eligible to be paid for in an ambulatory surgery center setting. We are waiting to see if they finalize these proposals when they release the Final Rule.
Q: How will the Medicare outpatient prospective payment system proposed rule affect gastroenterologists?
JB: CMS has proposed a new quality measure for ASCs and hospital outpatient departments, the Facility Seven-Day Risk Standardized Hospital Visit Rate After Outpatient Colonoscopy. While we recognize the need to move from process to outcomes measures, the incidence of complications following endoscopic procedures is very low. Will these measures truly be meaningful for ASCs and hospitals? We've made suggestions to CMS to develop quality measures in equipment reprocessing and anesthesia related measures regarding sedation safety in the ASC and will continue to advocate for quality measures that are meaningful to physicians and our patients.
Q: How will the proposed changes to the Medicare Physician Fee Schedule affect the field of GI?
JB: GI has undergone an unprecedented review of endoscopic codes. We have gone through a review of the upper GI endoscopy and ERCP codes, reflected as interim values in the 2014 fee schedule, and now CMS is moving towards review of lower GI codes. There is a significant concern that reimbursement for colonoscopy and other lower GI procedures could be reduced in 2015, without a chance for us to comment. There is a real need for transparency in the rate setting process. Because of the federal government shutdown last year, Medicare didn’t publish rates until Thanksgiving, and Gastroenterologists had only five weeks to adjust. Many physicians are operating small businesses, and need adequate time to prepare for changes.
Q: How are the GI societies working with CMS to change the process of assigning code values?
JB: In the interest of fairness, before Medicare finalizes value recommendations, the rate setting process needs to be as transparent as possible. The GI societies have asked CMS to delay any interim valuing of the lower endoscopy codes and delay finalizing the value for upper endoscopy codes for one year, until our questions have been resolved.
Valuing services, such as moderate sedation, can be difficult. When these codes were first proposed for review, we asked that endoscopy codes be valued separately from the administration of sedation or anesthesia. CMS did not do that, but it's becoming apparent that they may have seen the wisdom in our request. In the future, we could be facing a situation where moderate sedation needs to go through a thorough survey process. There are components of the provision of moderate sedation that occur before, during and after an endoscopic procedure. It would be inappropriate for CMS to simply assign a value without obtaining input from physicians who administer moderate sedation.
Q: Do the sister GI societies intend to continue these advocacy efforts?
JB: The GI societies continue to maintain a dialogue with CMS and others to address these issues.
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Question: Has CMS responded to advocacy efforts made in the past?
Dr. Joel Brill: In the proposed rules CMS made a number of suggestions that followed up on what the GI societies had previously suggested to the agency. CMS addressed several of our comments regarding inappropriate placement of ERCP and stenting procedures, and upper GI endoscopic mucosal resection (EMR) into ambulatory payment classifications (APC). We made recommendations in regards to putting capsule procedures into one APC and they agreed. They also responded to our request for the esophageal BRAVO procedure and proposed that it would be eligible to be paid for in an ambulatory surgery center setting. We are waiting to see if they finalize these proposals when they release the Final Rule.
Q: How will the Medicare outpatient prospective payment system proposed rule affect gastroenterologists?
JB: CMS has proposed a new quality measure for ASCs and hospital outpatient departments, the Facility Seven-Day Risk Standardized Hospital Visit Rate After Outpatient Colonoscopy. While we recognize the need to move from process to outcomes measures, the incidence of complications following endoscopic procedures is very low. Will these measures truly be meaningful for ASCs and hospitals? We've made suggestions to CMS to develop quality measures in equipment reprocessing and anesthesia related measures regarding sedation safety in the ASC and will continue to advocate for quality measures that are meaningful to physicians and our patients.
Q: How will the proposed changes to the Medicare Physician Fee Schedule affect the field of GI?
JB: GI has undergone an unprecedented review of endoscopic codes. We have gone through a review of the upper GI endoscopy and ERCP codes, reflected as interim values in the 2014 fee schedule, and now CMS is moving towards review of lower GI codes. There is a significant concern that reimbursement for colonoscopy and other lower GI procedures could be reduced in 2015, without a chance for us to comment. There is a real need for transparency in the rate setting process. Because of the federal government shutdown last year, Medicare didn’t publish rates until Thanksgiving, and Gastroenterologists had only five weeks to adjust. Many physicians are operating small businesses, and need adequate time to prepare for changes.
Q: How are the GI societies working with CMS to change the process of assigning code values?
JB: In the interest of fairness, before Medicare finalizes value recommendations, the rate setting process needs to be as transparent as possible. The GI societies have asked CMS to delay any interim valuing of the lower endoscopy codes and delay finalizing the value for upper endoscopy codes for one year, until our questions have been resolved.
Valuing services, such as moderate sedation, can be difficult. When these codes were first proposed for review, we asked that endoscopy codes be valued separately from the administration of sedation or anesthesia. CMS did not do that, but it's becoming apparent that they may have seen the wisdom in our request. In the future, we could be facing a situation where moderate sedation needs to go through a thorough survey process. There are components of the provision of moderate sedation that occur before, during and after an endoscopic procedure. It would be inappropriate for CMS to simply assign a value without obtaining input from physicians who administer moderate sedation.
Q: Do the sister GI societies intend to continue these advocacy efforts?
JB: The GI societies continue to maintain a dialogue with CMS and others to address these issues.
More articles on gastroenterology:
SAGES begins endoscopy safety program
New GI technology: 10 gastroenterologists on the most exciting advancements
7 gastroenterologists in the news