Proposed 2015 Medicare Payment and Policy Revisions for Physicians and ASCs Released

July 08, 2014

On July 3, CMS released the CY2015 Physician Fee Schedule (PFS) Proposed Rule and the CY2015 Hospital Outpatient Prospective Payment System (HOPPS)/ Ambulatory Surgical Center (ASC) Proposed Rule. These rules outline proposed changes that will take effect Jan. 1, 2015.

Key Information

  • Despite aggressive advocacy by AGA, ACG and ASGE, CMS did not include anticipated changes to payments for lower endoscopy, including colonoscopy, in the proposed rule. We anticipate that CMS will release proposed changes to the lower endoscopy codes in the November final rule, as they did with the upper endoscopy codes last year. We will continue to fight for fair colonoscopy reimbursement and transparency in the rulemaking process. Read our press statement.
  • Modifications to the upper endoscopy interim final values also were not included, although CMS anticipates addressing the interim upper endoscopy values in the final rule.  
  • CMS proposes to modify the process for valuing CPT codes, including potentially misvalued codes, to improve transparency. 

AGA, ACG and ASGE are committed to working together to advocate for fair reimbursement for GI procedures. Watch your email for details on how to get involved.

Keep reading for more information on key areas outlined above.  

Exclusion of Upper Endoscopy and Colonoscopy Code Values in the Proposed Rule

Our societies are disappointed that CMS did not include proposed values for colonoscopy in the proposed rule, which effectively precludes our societies from commenting on anticipated new  valuations before they take effect on Jan. 1, 2015. 

When CMS mandated that the GI societies resurvey all of the major endoscopy code families through its misvalued code initiative, the challenge to maintain the past value of endoscopic services was clear. For the past two years, our societies worked tirelessly to ensure accuracy in the valuation of GI endoscopic procedures through the AMA Relative Value Update (RVU) Committee and CMS.   

Together, AGA, ACG and ASGE are doing everything possible to provide CMS with the data it needs to appropriately value lower endoscopy codes, including colonoscopy, and to reverse CMS’ interim determination when finalizing the values for the upper endoscopy code families in the CY2015 Medicare physician fee schedule final rule.  

We understand the stakes are high and that is why in the past six months, our societies have met with CMS officials three times and have provided significant data questioning the validity of the new upper endoscopy interim values that took effect Jan. 1, 2014. In August, our societies will again meet with CMS to discuss CY2015 valuations for colonoscopy.    

In response to concerns expressed to CMS by our societies about the lack of transparency in the current rate setting process and to letters from House and Senate lawmakers, CMS is proposing to modify the process for establishing values for new, revised and potentially misvalued codes. Under the proposal, all changes to the work, malpractice RVUs, and direct practice inputs for new, revised and potentially misvalued services would first be published in a proposed rule to afford stakeholders adequate opportunity for analysis and comment. Our societies applaud the proposal, but are disappointed that CMS proposes that the new process take effect for the CY2016 rulemaking process, which, consequently, means that the colonoscopy codes now under review would not benefit from the changes. Our societies intend to argue that potentially misvalued codes now under review should be captured in this proposal.  

Other Highlights

  • CMS proposes to increase Physician Quality Reporting System (PQRS) requirements and expands the physician Value-Based Payment (VBP) Modifier program.
  • The ASC payment update is proposed at 1.2 percent for CY2015, and CMS proposes the addition of a new colonoscopy measure in the ASC Quality Reporting Program.

Medicare Physician Fee Schedule

Physician Payment Update

Absent congressional intervention, physicians face an estimated 20 percent cut on April 1, 2015, due to the flawed sustainable growth rate (SGR) formula. Congress has provided temporary relief from negative updates every year since 2003, including the current 12-month temporary reprieve from payment cuts. The GI societies will advocate for Congress to intervene to stop the cuts once again.

While the 2015 estimated impact on allowed charges for gastroenterology shows no change, additional changes to both upper and lower codes in the final rule could make the overall impact of these changes greater.

Physician Quality Reporting System & Value-Based Payment Modifier Programs 

In 2015, physicians and other eligible professionals must satisfactorily participate in the Physician Quality Reporting System (PQRS) to avoid a -2 percent payment adjustment to Medicare Part B fee for service payments in 2017. To avoid the adjustment, CMS proposes that in 2015, eligible professionals will need to report nine measures across three quality domains for at least 50 percent of their Medicare Part B fee for service patients. This is a significant change, as in 2014 eligible professionals were required to report three measures to avoid the 2016 payment adjustment. Beginning in 2015, physicians with less than nine measures would be allowed to report on fewer, but would be subject to the measure application validation process. 

In attempt to gain a better overall picture of care provided, particularly for the value-based payment modifier (VBPM) assessment, CMS is newly proposing that of the nine measures, eligible professionals who report via registry or claims would be required to report on at last two of 18 CMS-specified cross-cutting measures.  

CMS is also proposing to eliminate the claims-based reporting option for a number of measures beginning in 2015, including the endoscopy measures (#185, #320) and colorectal cancer screening measure (#113). 

As required by law, the proposed rule also lays out the proposed requirements for applying the VBPM to all physicians by 2017. The proposed rule also expands the program by applying the VBPM to all non-physician eligible professionals, increases the amount of payment at risk, and refines the methodologies for determining quality and cost scores. All physicians (categorized as a group of two or more eligible professionals or solo practitioner) will be subject to quality tiering under the program. Only solo practitioners and groups of two to nine eligible professionals will be held harmless from any downward adjustments in 2017, for which 2015 is the performance year. CMS has increased the maximum downward adjustment that any physician (or group of physicians) could receive from -2 to -4 percent. The VBPM will continue to be tied to an eligible professional’s successful participation in PQRS, putting eligible professionals at risk for an adjustment of -6 percent for failure to satisfactorily participate in PQRS. 

Patient Cost-Sharing for Screening Colonoscopy

Citing an increasing number of colonoscopies in which anesthesia is separately furnished using an anesthesia professional, CMS is proposing to to redefine a colorectal cancer screening test to include anesthesia that is separately furnished in conjunction with a screening colonoscopy. Consequently, the Medicare beneficiary Part B deductible and coinsurance will be waived for anesthesia services separately furnished by an anesthesia professional in conjunction with a screening colonoscopy. While our societies appreciate that CMS contends that it is proposing this change to eliminate a financial barrier to screening tests, we are deeply disappointed that CMS is not using the same regulatory authority to waive coinsurance for a screening with polyp removal. 

ASC Payment System

ASC Payment Update

For 2015, CMS is proposing a 1.2 percent update to ambulatory surgical center (ASC) payments, the same as the 2014 update. CMS continues to use the Consumer Price Index for All Urban Consumers (CPI-U) for calculating the update. CMS estimates CPI-U to be 1.7 percent. However, as required by law, any ASC update must be reduced by a productivity adjustment. For 2015, CMS estimates the multifactor productivity adjustment to be 0.5 percent, resulting in the 1.2 percent update. The proposed ASC conversion factor increases slightly in CY2015 to $43.918 from $43.471 in CY2014.

Our societies have argued that the CPI-U is not an appropriate update factor for ASCs and have argued that ASCs and hospital outpatient payments should be updated using the same inflation factor — the hospital market basket index. The 2015 proposed hospital outpatient department update is 2.1 percent.

ASC Quality Reporting Program

As required by law, ASCs would continue to be penalized -2 percent for unsuccessful participation in the ASC Quality Reporting Program. CMS does not propose any significant changes to the program, but proposes the inclusion of a new colonoscopy measure — Facility Seven-Day Risk Standardized Hospital Visit Rate after Outpatient Colonoscopy. The measure will be used for the CY2017 payment determination and based on claims from July 1, 2014, through June 30, 2015, and excludes certain patients who are at higher risk for hospital visits. ASCs would not be liable for reporting any additional data beyond claims.

Our societies are analyzing both proposed rules and will be drafting a joint letter to CMS. We will provide members the detailed information necessary to begin preparing their practices for the pending payment and policy changes.

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