On Monday, July 29, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2020 proposed rules for the Physician Fee Schedule (PFS), Outpatient Prospective Payment System (OPPS) and Quality Payment Program, which include several significant policy and payment changes impacting gastroenterologists.
Here is a topline summary of the most important proposed changes to the payment rates and policies for services paid under Medicare.
- CMS walks back recently proposed changes to collapse E/M levels: In the 2019 Medicare PFS rule, CMS finalized a policy to collapse payment for evaluation and management (E/M) levels 2-4 for office/outpatient established and new patients to begin in CY 2021. However, CMS is reversing course to align with recent changes laid out by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel, which retains five levels of coding for established patients, reduces the number of levels to four for new patients, and revises the code definitions. The CPT changes also revise the times and medical decision-making process for all of the codes and require performance of history and exam only as medically appropriate. The CPT code changes allow clinicians to choose the E/M visit level based on either medical decision making or time.
Welcomed news: This is welcomed news as the GI societies opposed CMS’ proposal when it was announced last year. We worked with the AMA and a coalition of specialty societies in an effort to get CMS to rethink collapsing payment for E/M code levels, and subsequently decided to support the AMA’s proposed E/M changes as they moved through the CPT and Relative Value Scale Update Committee (RUC) processes. In the rule, CMS abandons its indentproposal and adopts the AMA CPT changes and RUC valuation.
- CMS seeks feedback on requiring providers to give notice of post-polypectomy surprise billing. Under current law, Medicare beneficiaries are subject to cost-sharing when a screening colonoscopy turns therapeutic, but not when the procedure remains a “screening.” Resolving this coverage quirk has been a major policy initiative for the GI societies. In the past, CMS officials have concluded that the agency does not have the regulatory authority to fix this process, thus requiring a change in the law. CMS is now seeking feedback on whether providers should be required to notify patients of this potential problem prior to performing the screening.
GI societies disappointed: With this proposal, CMS is adding to the confusion
indentand problem, especially as hundreds of public and private organizations have come together with the common goal of increasing screening rates. The GI societies instead urge CMS to fix this cost-sharing quirk via regulations or implore Congress to pass bipartisan legislation that deals with this problem if CMS does not have the regulatory authority to do so (Removing Barriers to Colorectal Cancer Screening Act [S.668/HR 1570]). CMS proposes to further burden endoscopists by potentially requiring patient notification of surprise bills, instead of doing more to resolve the issue to eliminate the surprise bill in the first place.
- Slight increase in MPFS conversion factor: The proposed CY 2020 PFS conversion factor is $36.09, a slight increase above the CY 2019 PFS conversion factor of $36.04.
Proposed CY 2020 Medicare reimbursement rates for common GI procedures (national average)
|CPT code||2020 proposed national Medicare rate (facility)||2019 national Medicare rate (facility)|
|43235 (Egd diagnostic brush wash)||$126.14||$129.02|
|43239 (Egd biopsy single/multiple)||$142.00||$145.96|
|45378 (Diagnostic colonoscopy)||$191.37||$194.97|
|45380 (Colonoscopy and biopsy)||$207.59||$211.55|
|45385(Colonoscopy w/lesion removal)||$263.09||$268.49|
|G0121 (Screening colonoscopy; not high risk)||$192.09||$194.97|
- Click Here for the CY 2020 Medicare fee for services RVU chart for selected GI services.
- Click Here for the CY 2020 proposed Medicare E/M RVUs chart.
Quality Payment Program
Key proposals for 2020 performance year of the QPP:
- Increase performance threshold from 30 points to 45 points.
- Reduce Quality performance category weight to 40 percent in 2020, 35 percent in 2021, and 30 percent in 2022.
- Increase Cost performance category weight to 20 percent in 2020, 25 percent in 2021, and 30 percent in 2022.
- Increase data completeness threshold for submitting quality data.
- Increase threshold for clinicians who complete or participate in the Improvement Activity performance category for group reporting.
- Allow alternative payment model (APM) entities and Merit-based Incentive Payment System (MIPS)-eligible clinicians participating in APMs the option to report on MIPS quality measures for the MIPS Quality performance category.
- Give a MIPS APM Quality Reporting Credit for APM participants in other MIPS APMs where quality scoring through the APM is not technically feasible.
MIPS category performance weights (2019 vs. proposed 2020)
|MIPS category||2019||Proposed 2020|
CMS proposes removal of two colonoscopy measures from MIPS performance year 2022: CMS proposes removing Measure 343 (Screening Colonoscopy Adenoma Detection Rate), claiming that it does not account for variables which may influence adenoma detection rate and that, due to its construction, benchmarks calculated from this measure are misrepresented and do not align with MIPS scoring methodology. CMS also proposes removing Measure 185 (Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use).
Slight increase on OPPS and ASC conversion factors: CMS proposes updating both OPPS and ambulatory surgery center (ASC) payment rates by 2.7%. Last year, CMS finalized its proposal to apply the hospital market basket update to ASC payment system rates for an interim period of five years (CY 2019 through CY 2023). CMS is not proposing any changes to this policy.
Proposed CY 2020 Medicare facility fees for common GI procedures
|CPT code||CY 2020 proposed ASC Medicare rate||2019 ASC Medicare facility fee||CY 2020 proposed HOPD Medicare facility fee||2019 HOPD Medicare facility fee|
|43235 (Egd diagnostic brush wash)||$395.98||$392.11||$797.37||$761.55|
|43239 (Egd biopsy single/multiple)||$395.98||$392.11||$797.37||$761.55|
|45378 (Diagnostic colonoscopy)||$385.65||$383.53||$776.56||$744.89|
|45380 (Colonoscopy and biopsy)||$508.57||$504.47||$1024.08||$979.79|
|45385(Colonoscopy w/lesion removal)||$508.57||$508.47||$1,024.08||$1,024.08/|
|G0121 (Screening colonoscopy; not high risk)||$385.65||$383.53||$776.56||$744.89|
- Click Here for the proposed CY 2020 HOPD Medicare facility fees for selected GI services.
- Click Here for the proposed CY 2020 HOPD Medicare facility fees for the top 10 GI base and biopsy codes.
- Click Here for the proposed CY 2020 ASC Medicare facility fees for selected GI services.
- Click Here for the proposed CY 2020 ASC Medicare facility fees for the top 10 GI base and biopsy codes.
ACG, AGA and ASGE are currently reviewing the details of the proposed rules and will be providing joint comments. CMS will accept comments until Sept. 27, 2019. We expect the final rule to be issued around November 2019. We will keep you updated as we learn more.
- Click Here to read the CY 2020 Medicare PFS proposed rule fact sheet.
- Click Here to read the CY 2020 Medicare PFS proposed rule.
- Click Here to read the CY 2020 Medicare OPPS proposed rule fact sheet.
- Click Here to read the CY 2020 Medicare OPPS proposed rule.
- Click Here to read the CY 2020 Medicare QPP proposed changes fact sheet.