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Proposed Medicare rule includes good news for GI procedure reimbursement

CMS released the calendar year (CY) 2022 Hospital Outpatient Prospective Payment System (OPPS)/Ambulatory Surgery Center (ASC) Proposed Rule.
woman doctor work and use a computer with green screen monitor in the clinic
woman doctor work and use a computer with green screen monitor in the clinic

What you need to know

  • The conversion factors increase 2.3% to $84.46 for hospital outpatient departments and $50.04 for ASCs meeting the quality reporting requirements
  • GI procedure payments are expected to increase 3%
  • Peroral endoscopic myotomy (POEM) and colon capsule endoscopy get new codes and payments

 

Payment charts

CY 2022 Proposed ASC Payment Rates for Top GI Codes
CY 2022 Proposed ASC Payment Rates
CY 2022 Proposed HOPD Payment Rates for Top GI Codes
CY 2022 Proposed HOPD Payment Rates

The GI societies are beginning our analysis of the Medicare OPPS/ASC Proposed Rule and the Medicare physician fee schedule (released last week) and plan to submit comments together.

Conversion factors

The CY 2022 OPPS/ASC rule proposes a conversion factor of $84.46 for hospitals meeting facility quality reporting requirements, an update of 2.3%.

The proposed CY 2022 ASC conversion factor is $50.04 for ASCs meeting quality reporting requirements, an update of 2.3%. GI procedure payments will increase on average 3% in CY 2022.

POEM and colon capsule endoscopy payments

CMS’ proposed payment for POEM is $3,160.76 in the hospital outpatient setting and $1,848.32 in the ASC. The placeholder CPT code is 434XX. A permanent code will be released in the 2022 CPT book later this year.

CMS’ proposed payment for colon capsule endoscopy is $814.44 in the hospital outpatient setting. The placeholder CPT code is 9111X. A permanent code will also be released in the 2022 CPT book.

Implementation of the Removing Barriers to Colorectal Cancer Screening Act

CMS plans to implement changes made last year by Congress to beneficiary cost-sharing obligations when a polyp or other growth is found and removed as part of a screening colonoscopy or screening flexible sigmoidoscopy. Beginning Jan. 1, 2022, beneficiary coinsurance will be 20%, phasing out to zero by Jan. 1, 2030. In the OPPS/ASC proposed rule, Medicare proposes that providers must continue to report HCPCS modifier “PT” to indicate that a planned colorectal cancer screening service converted to a diagnostic service during the transition period. Thank you GI society members for all of your advocacy efforts over the years to make this change happen!

Procedures payable in the ASC

CMS is proposing to reinstate the patient safety criteria it uses to evaluate whether a procedure should be payable in the ASC setting. These criteria will be used for procedures that were removed in 2021. The agency is proposing to adopt a nomination process whereby the public can formally nominate procedures it believes are safe to perform for the Medicare population in the ASC setting.

Quality Payment Programs

The Hospital Outpatient Quality Reporting (OQR) Program and Ambulatory Surgical Center Quality Reporting (ASCQR) Program require quality reporting requirements be met or receive a cut of 2% in their annual fee schedule update.

CMS has identified six priority measures included in the Hospital Outpatient Quality Reporting (OQR) Program as candidate measures for disparities reporting stratified by dual eligibility, one of which is the Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy (OP-32).

Additionally, CMS is proposing to adopt a new COVID-19 vaccination measure among health care personnel for the ASCQR Program, which ASCs would be required to report quarterly beginning Jan. 1, 2022. CMS would also reinstate the following ASC measures beginning with the CY 2025 payment determination: (a) ASC-1: Patient Burn; (b) ASC-2: Patient Fall; (c) ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant; and (d) ASC-4: All-Cause Hospital Transfer/Admission.

The GI societies are beginning our analysis of the Medicare OPPS/ASC Proposed Rule and will be submitting comments together.

Additional resources

CMS’ press release on the proposed rule
A fact sheet summarizing the proposed rule
The OPPS/ASC proposed rule

The rule will be posted in the Federal Register on Aug. 4, 2021.

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