Coding and Reimbursement
This resource center has been developed by the Practice Management Committee to assist ASGE members in properly coding gastrointestinal endoscopy services. Here you will find coding tip sheets, coding updates and coding instructions.
The updated ICD-10-CM system was adopted in October of 2015, consisting of codes that use 3-7 digits instead of 3-5 digits to be used in all U.S. health care settings. ICD-10 replaced a 30 year old system that used outdated terms and was limited in potential for new codes.
The Medicare physician payment schedule determines the reimbursement rates for all Medicare Part B Services. Every summer, CMS releases a proposed rule regarding the upcoming year's physician payment schedule. In this major proposed rule, CMS proposes relative value units (RVUs) for the upcoming year, updates to geographic practice cost indexes and changes to other Medicare Part B payment policies. The proposed rule also details changes and updates to the CMS Quality Programs. The physician payment schedule final rule is published in the fall.
The ASC is an important part of the practice of gastroenterology, providing a safe, patient friendly and cost effective environment for the provision of medical services. About 40 percent of all colonoscopies are provided in ASCs and the majority of ASCs, in which gastroenterologist practice, are single specialty centers. Because of their single specialty structure, gastrointestinal ASCs are particularly sensitive to changes in Medicare payments. Medicare reimbursement for gastrointestinal services, provided in the ASC setting, have been declining causing a widening disparity between payment rates for ASCs and the hospital outpatient departments (HOPDs).
In 1992, Medicare implemented a cost-based physician fee schedule. For each of the greater 7,000 services on the fee schedule, an RVU is assigned based on the time and intensity of physician work, practice expense and cost of professional liability insurance necessary to provide the service. To determine the Medicare fee, a service's RVUs are multiplied by a dollar conversion factor that is updated annually. A geographic adjustment is also made.
When Medicare transitioned to a physician payment system based on the Resource-Based Relative Value Scale (RBRVS), the AMA anticipated the effects of this change and formulated a multi-specialty committee. This committee, known as the AMA RVS Update Committee (RUC), has made numerous recommendations to CMS that have significantly affected the Medicare physician payment schedule by giving physicians a voice in shaping Medicare relative values. The RUC, in conjunction with the Current Procedural Terminology Editorial Panel, has created a process through which specialty societies can develop relative value recommendations for new and revised codes. The RUC carefully reviews survey data presented by specialty societies and develops recommendations for consideration by CMS. ASGE and AGA are active participants in the RUC.
The American Gastroenterological Association (AGA), the American College of Gastroenterology (ACG) and the American Society for Gastrointestinal Endoscopy (ASGE) have an active role in establishing and/or revising CPT codes for new and existing procedures, relevant to the practice of gastroenterology.