Practice Guidance

Reimbursement

Physician reimbursement and coding are vital to the sustainability of every physician’s practice. AGA develops tools and education to support the economic and operational needs of members across the spectrum of practice.

Medicare Payment Rules

Things to know about the 2021 Proposed Medicare payment rules

Physician payments across most specialties likely to be cut.

AGA, ACG and ASGE outline revisions to physician fee schedule payment policies and the quality payment program affecting GI practice.

CMS has released two calendar year (CY) 2018 rules that finalize policy and payment changes for the Medicare Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Centers (ASC) Payment System.

CMS finalized the CY 2018 conversion factor at $45.575 for ASCs that meet quality reporting requirements. Effective adjusted update factor is 1.2 percent.

The 2018 PFS conversion factor is $35.99, an increase of +0.41 percent from the 2017 PFS conversion factor of $35.89.

CMS finalized the CY 2018 conversion factor at $78.636 for those that meeting quality reporting requirements. The effective update is 1.35 percent.

If a health care provider is eligible to participate in the Medicare EHR Incentive Program, they must demonstrate meaningful use each year to avoid a payment adjustment.

Reimbursement on the hill

COVID-19 reimbursement resources

Current Procedural Terminology® (CPT) was first developed and published by the American Medical Association (AMA) in 1966. The original purpose of CPT was to standardize the categorization of the types of services provided by physicians. We are currently using the 4th Edition of CPT, CPT-4. Originally, CPT was not intended to be utilized for purposes of reimbursement.

In 1983, the Health Care Financing Administration, now the Centers for Medicare and Medicaid Services (CMS), mandated CPT be used for Medicare billing along with their system, Healthcare Common Procedure Coding System (HCPCS). Today, most third party payors also require that practices report CPT codes when billing for visits and procedures.

AGA works cooperatively with ACG and ASGE to establish and/or revise CPT codes for new/existing procedures relevant to the practice of gastroenterology. In recent years, the societies have introduced over 60 codes through the CPT Editorial Panel. Representatives and advisors from the three GI societies are in constant communication and attend the three CPT Editorial Panel meetings held each year.

Anyone can submit a proposal to the AMA for a new or revised CPT code. The GI societies are constantly engaged with members, industry, payors and other stakeholders to review the CPT code set and determine appropriate timing for recommending any code additions, revisions or deletions. Learn more about the process.

CPT codes are divided into three categories

CATEGORY I

Category I codes must meet the following minimum criteria:

  • The service/procedure has received approval from the Food and Drug Administration (FDA) for the specific use of devices or drugs.
  • The suggested procedure/service is a distinct service performed by many physicians/practitioners across the United States.
  • The clinical efficacy of the service/procedure is well established and documented in U.S. peer-review literature.
  • The suggested service/procedure is neither a fragmentation of an existing procedure/service nor currently reportable by one or more existing codes.
  • The suggested service/procedure is not requested as a means to report extraordinary circumstances related to the performance of a procedure/service already having a specific CPT code.
CATEGORY II

Category II codes are reserved for codes used to report performance and quality measures.

CATEGORY III

Category III codes must meet the following minimum criteria:

  • A protocol of the study or procedures being performed.
  • Support from the specialties who would use this procedure.
  • Availability of United States peer-reviewed literature for examination by the CPT Editorial Panel.
  • Descriptions of current United States trials outlining the efficacy of the procedure.

If applying for a Category I or Category III code, the CPT Editorial Panel votes and determines into which category the code(s) should be assigned.

More information about CPT can be found at the AMA website.

Innovative GI Payment Models

Policymakers are exploring alternatives to fee-for-service payment. “Bundled payment” is an alternative payment model that rewards providers for identifying efficiency gains, effectively coordinating patient care and improving quality. AGA is committed to preparing you for success in new reimbursement environments.

What is a bundled payment?

  • Single payment for a condition or treatment.
  • Covers a pre-defined set of services across multiple providers and multiple settings.
  • Aims to improve the value of health care (quality/cost) by:
    • Controlling costs.
    • Improving collaboration among providers.
    • Improving patient outcomes and reducing the incidence of complications.

AGA Colonoscopy Bundled Payment Model

AGA developed a bundled payment framework for colonoscopy performed for colorectal cancer screening or surveillance. AGA does not recommend a payment rate for a colonoscopy bundle. Physicians who cannot quantify costs, appropriateness and health outcomes for colonoscopy could see a negative impact on practice revenue.

AGA Episode Payment Framework for Gastroesophageal Reflux Disease (GERD)

This article outlines a collaborative approach involving multiple stakeholders for practices to assess their ability to participate in and implement an alternative payment model for gastroesophageal reflux disease.

Included in the episode framework are patients with esophageal and extraesophageal syndromes, including those with Barrett’s esophagus with or without dysplasia, but excluding Barrett’s esophagus-associated adenocarcinoma.

AGA Episode of Care Framework for Obesity Management

The AGA Obesity Episode of Care Bundle encompasses multi-disciplinary, non-surgical and endoscopic management of obesity and incorporates coding recommendations for services not routinely encountered by gastroenterologists. It includes a hybrid episode payment model that identifies those services eligible under the Affordable Care Act / insurance versus those paid out-of-pocket.