2016-11-03 13:15:19 UTC

CMS Releases 2017 Medicare Physician Fee Schedule Final Rule

Nov. 3, 2016

CMS created new moderate sedation codes for GI endoscopy procedures, which need to be billed separately.

This week CMS released the 2017 Medicare Physician Fee Schedule final rule. AGA, ACG and ASGE are currently reviewing the details of the final rule and will provide a more extensive summary soon. 

This communication offers a topline summary of CMS’ finalized policy for moderate sedation in endoscopy, which has the greatest potential to affect GI clinicians. For calendar year (CY) 2017, CMS finalized its proposal to separate moderate sedation services from hundreds of procedure codes, including the majority of GI endoscopy procedures under Medicare Part B.


What This Means for You:

  • There will be no financial impact for gastroenterologists who perform their own moderate sedation. Gastroenterologists performing their own moderate sedation for endoscopic procedures will now report two codes instead of one —  the procedure code and the proposed moderate sedation code — beginning Jan. 1, 2017.
  • Gastroenterologists who use anesthesia professionals will see the value of the majority of all GI endoscopy procedures reduced by 0.10 RVUs. The reduction is less onerous than the 0.22 RVUs recommended by the AMA Relative Value Update Committee (RUC) and the 0.25 RVUs finalized by CMS  for all other specialties’ procedures for which the value of moderate sedation is currently inherent to the procedure.

In making this change, CMS acted in accordance with member survey data provided by the GI societies. Based on these survey responses, AGA, ACG and ASGE provided information to CMS in-person and via written comments that moderate sedation, when provided by the endoscopist for GI endoscopy, is different work than for other procedures, such as pain management. In response, CMS has created a separate Healthcare Common Procedure Coding System (HCPCS) G code (G0500) for moderate sedation for GI endoscopy procedures.

Background on Moderate Sedation Services Under Medicare 
CMS announced in 2014 that the agency wanted to separate moderate sedation services from procedure codes in all specialties, including gastrointestinal endoscopy procedures, in which the underlying service was originally valued with moderate sedation. Until now, the agency has never placed a value on this moderate sedation work. For several years, the three GI societies have been working on behalf of gastroenterologists to educate CMS on this issue

Final Values for Moderate Sedation 2017
The final value for moderate sedation for GI endoscopic procedures for 2017 is 0.10 work RVUs. Additional time may be reported with CPT code +99153, for each additional 15 minutes of intra-service time as appropriate. However, code +99153 will only have practice expense; no physician work.


HCPCS Code   Physician Work RVU
G0500 Moderate sedation services provided by the same physician or other qualified health-care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older. 0.10


RVU Changes for 2017 
Here are the 2017 Medicare physician work RVUs for the most commonly performed GI services:

Moderate Sedation Administered by the Same Provider

CPT Short Desciptor 2016 Work RVU 2017 Final Work RVU (Procedure + Moderate Sedation) Proposed % RVU Change
43235 + G0500 Egd diagnostic brush wash + moderate sedation 2.19 2.09 + 0.10 0%
43239 + G0500 Egd biopsy single/multiple + moderate sedation 2.49 2.39 + 0.10 0%
43246 + G0500 Egd place gastrostomy tube + moderate sedation 3.66 3.56 + 0.10 0%
43248 + G0500 Egd guide wire insertion + moderate sedation 3.01 2.91 + 0.10 0%
43249 + G0500 Esoph egd dilation <30 mm + moderate sedation 2.77 2.67 + 0.10 0%
45378 + G0500 Diagnostic colonoscopy + moderate sedation 3.36 3.26 + 0.10 0%
45380 + G0500 Colonoscopy and biopsy + moderate sedation 3.66 3.56 + 0.10 0%
45381 + G0500 Colonoscopy submucous inj + moderate sedation 3.66 3.56 + 0.10 0%
45384 + G0500 Lesion remove colonoscopy + moderate sedation 4.17 4.07 + 0.10 0%
45385 +G0500 Lesional removal + moderate sedation 4.67 4.57 + 0.10 0%


Sedation Administered by an Anesthesia Professional (e.g., MAC, general anesthesia)

CPT Short Descriptor 2016 Work RVU 2017 Work RVU % RVU Change
43235 Egd diagnostic brush wash 2.19 2.09 -5%
43239 Egd biopsy single/multiple 2.49 2.39 -4%
43246 Egd place gastostomy tube 3.66 3.56 -3%
43248 Egd guide wire insertion 3.01 2.91 -3%
43249 Esoph egd dilation <30mm 2.77 2.67 -4%
45378 Diagnostic colonoscopy 3.36 3.26 -3%
45380 Colonoscopy and biopsy 3.66 3.56 -3%
45381 Colonoscopy submucous inj 3.66 3.56 -3%
45384 Lesion remove colonoscopy 4.17 4.07 -2%
45385 Lesional removal colonoscopy 4.67 4.57 -2%

GI Anesthesia Services Under Review
For 2017, CMS maintained the base value for the codes for anesthesia provided for upper (00740) and lower (00810) GI endoscopy on an interim basis. CMS continues to believe that the services are potentially misvalued and will continue to seek outside input as the codes are moving through the CPT and RUC processes.

Next Steps
AGA, ACG and ASGE are currently reviewing the details of the final rule and will provide a more extensive summary of the entire rule soon. 

The final rule will be published in the Federal Register on Nov. 15, 2016. Our societies will be analyzing the rule and providing comments to CMS.  

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