Colonoscopy Bundle vs. Medicare Payment Model

August 14, 2014

In this turbulent environment, stakeholders — patients, payors, purchasers — expect good value for the services provided by physicians. To help gastroenterologists meet these expectations, AGA developed a bundled payment model for screening and surveillance colonoscopy.

By developing a framework and educating gastroenterologists about value-based reimbursement, AGA hopes to inform physicians who wish to consider contracting with payors, purchasers and risk-bearing organizations around new payment models. Here, AGA clarifies some recent confusion about the differences between bundled payments and the Medicare review of physician work and reimbursement for colonoscopy procedures.

Q: How does Medicare currently reimburse for colonoscopy? Is it expected to change?
A: Colonoscopy procedures are part of the Medicare Physician Fee Schedule, a fee-for-service (FFS) payment system. Colonoscopies have zero-day global periods, meaning that post-operative visits after the day of the procedure, including visits for post-procedure complications, are separately reportable.

In 2011, CMS identified colonoscopy and other GI endoscopy procedures as potentially misvalued. Nearly all GI endoscopy codes were reviewed by the AMA/Specialty Society Relative Value Scale Update Committee (RUC) and submitted to CMS, which makes the final payment determinations. 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. Changes will become effective for calendar year 2015. AGA, ACG and ASGE are advocating together for fair reimbursement for GI procedures (read more at www.valueofcolonoscopy.org).

Q: What is the AGA colonoscopy bundled payment model?
A: AGA created the bundled payment model for colonoscopy performed for colorectal cancer screening or surveillance to help members explore alternatives to FFS reimbursement. In this model, payments to providers are based on the expected costs of a grouping, or “bundle,” of related health-care services. The intent of bundled payments is to decrease waste while improving quality of care and coordination among providers.

Q: Should my practice incorporate the bundle payment model?
A: While bundled payment models are gaining momentum, there is no mandate that GI practices must explore this payment for colonoscopy or other GI procedures or services.

The decision to investigate bundled payments should be based on local market activity, payor receptivity to bundles, patient mix and other factors. Should your practice decide to pilot a bundled payment, the AGA colonoscopy bundle is a useful framework for negotiating with payors, and allows customization to the particular needs of each organization.

Learn more about bundled payment options.

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