Two CMS policy changes — a 2.5% efficiency adjustment to work RVUs for non-time-based services and a revision to the practice expense methodology — will cut payments to gastroenterologists for ASC and hospital-based endoscopy by $58 million, while boosting payments to gastroenterologists who perform office-based endoscopy by more than $37 million.
At the procedure level, office-based endoscopy procedures will see an average 16% Medicare payment increase, while ASCs and hospital outpatient departments face an average 8% cut.
Here are five things to know:
1. According to the American Gastroenterological Association, CMS’ motive for boosting payments in the office setting while cutting physician payments in the ASC and HOPD settings is the belief that physicians who perform procedures in those settings have lower costs for maintaining an office, and the desire to incentivize procedures in the lowest-cost setting.
2. A practice that does 900 colonoscopies (CPT 45378) per year could see a $45,891 increase in Medicare payment just for that procedure, according to the AGA. A practice doing 800 level 5 established patient office visits (CPT 99215) per year could see a $13,760 increase just for that code.
3. In several states — including Illinois, Oregon, Virginia, Washington and Wisconsin — health plans are introducing programs to promote the transition of outpatient endoscopy to office settings rather than hospital-based or ASC-based settings due to costs, according to a practice management editorial published in Clinical Gastroenterology and Hepatology.
4. Neil Gupta, MD, managing partner at Midwest Digestive Health & Nutrition in Des Plaines, Ill., which performs about 5,000 GI endoscopy procedures per year in an office setting, told Medscape the decision to offer office-based endoscopy was “an easy one.” He said it provides patients with a convenient, accessible endoscopy that is high quality and more affordable than hospital-based settings.
Beyond the financial dynamics, office-based endoscopy can help independent GI practices regain control of scheduling, clinical protocols and financial decisions without the involvement of ASC managers, investors or health system partners.5. According to the American Gastroenterological Association, converting to office-based endoscopy isn’t feasible for every practice. Key considerations include verifying state regulations (some states trigger specific requirements based on anesthesia use or capital thresholds), understanding payer environments and starting with the right case mix, typically low-acuity ASA I–II patients undergoing short diagnostic or surveillance procedures like EGD or non-complex colonoscopy.
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