Released on Jul 21, 2021

Proposed Medicare rule includes good news for GI procedure reimbursement

On July 19, 2021 the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2022 Hospital Outpatient Prospective Payment System (OPPS)/Ambulatory Surgery Center (ASC) Proposed Rule.
 

What you need to know:

  • The conversion factors increase 2.3% to $84.46 for hospital outpatient departments and $50.04 for ASCs meeting the quality reporting requirements
  • GI procedure payments are expected to increase 3%
  • Peroral endoscopic myotomy (POEM) and colon capsule endoscopy get new codes and payments

Payment Charts

 
The GI societies are beginning our analysis of the Medicare OPPS/ASC Proposed Rule and the Medicare physician fee schedule (released last week) and plan to submit comments together.
 

Conversion Factors

The CY 2022 OPPS/ASC rule proposes a conversion factor of $84.46 for hospitals meeting facility quality reporting requirements, an update of 2.3%. 
 
The proposed CY 2022 ASC conversion factor is $50.04 for ASCs meeting quality reporting requirements, an update of 2.3%. GI procedure payments will increase on average 3% in CY 2022. 
 

POEM and Colon Capsule Endoscopy Payments

CMS’ proposed payment for POEM is $3,160.76 in the hospital outpatient setting and $1,848.32 in the ASC. The placeholder CPT code is 434XX. A permanent code will be released in the 2022 CPT book later this year.
 
CMS’ proposed payment for colon capsule endoscopy is $814.44 in the hospital outpatient setting. The placeholder CPT code is 9111X. A permanent code will also be released in the 2022 CPT book.
 

Implementation of the Removing Barriers to Colorectal Cancer Screening Act

CMS plans to implement changes made last year by Congress to beneficiary cost-sharing obligations when a polyp or other growth is found and removed as part of a screening colonoscopy or screening flexible sigmoidoscopy. Beginning Jan. 1, 2022, beneficiary coinsurance will be 20%, phasing out to zero by Jan. 1, 2030. In the OPPS/ASC proposed rule, Medicare proposes that providers must continue to report HCPCS modifier “PT” to indicate that a planned colorectal cancer screening service converted to a diagnostic service during the transition period. Thank you GI society members for all of your advocacy efforts over the years to make this change happen!
 

Procedures Payable in the ASC

CMS is proposing to reinstate the patient safety criteria it uses to evaluate whether a procedure should be payable in the ASC setting. These criteria will be used for procedures that were removed in 2021. The agency is proposing to adopt a nomination process whereby the public can formally nominate procedures it believes are safe to perform for the Medicare population in the ASC setting.
 

Quality Payment Programs

The Hospital Outpatient Quality Reporting (OQR) Program and Ambulatory Surgical Center Quality Reporting (ASCQR) Program require quality reporting requirements be met or receive a cut of 2% in their annual fee schedule update.
 
CMS has identified six priority measures included in the Hospital Outpatient Quality Reporting (OQR) Program as candidate measures for disparities reporting stratified by dual eligibility, one of which is the Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy (OP-32).
 
Additionally, CMS is proposing to adopt a new COVID-19 vaccination measure among health care personnel for the ASCQR Program, which ASCs would be required to report quarterly beginning Jan. 1, 2022. CMS would also reinstate the following ASC measures beginning with the CY 2025 payment determination: (a) ASC-1: Patient Burn; (b) ASC-2: Patient Fall; (c) ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant; and (d) ASC-4: All-Cause Hospital Transfer/Admission.
 
The GI societies are beginning our analysis of the Medicare OPPS/ASC Proposed Rule and will be submitting comments together.
 

Additional Resources

 
The rule will be posted in the Federal Register on Aug. 4, 2021. 

Thank you for the opportunity to provide feedback.  Should you need additional information please contact us directly.

 


American Gastroenterological
Association

communications@gastro.org
(301) 654-2055
www.gastro.org

 American College of Gastroenterology
info@gi.org
(301) 263-9000
www.gi.org

 American Society for Gastrointestinal Endoscopy
info@asge.org
(630) 570-0600
www.asge.org







About Gastrointestinal Endoscopy
Gastrointestinal endoscopic procedures allow the gastroenterologist to visually inspect the upper gastrointestinal tract (esophagus, stomach and duodenum) and the lower bowel (colon and rectum) through an endoscope, a thin, flexible device with a lighted end and a powerful lens system. Endoscopy has been a major advance in the treatment of gastrointestinal diseases. For example, the use of endoscopes allows the detection of ulcers, cancers, polyps and sites of internal bleeding. Through endoscopy, tissue samples (biopsies) may be obtained, areas of blockage can be opened and active bleeding can be stopped. Polyps in the colon can be removed, which has been shown to prevent colon cancer.

About the American Society for Gastrointestinal Endoscopy
Since its founding in 1941, the American Society for Gastrointestinal Endoscopy (ASGE) has been dedicated to advancing patient care and digestive health by promoting excellence and innovation in gastrointestinal endoscopy. ASGE, with more than 15,000 members worldwide, promotes the highest standards for endoscopic training and practice, fosters endoscopic research, recognizes distinguished contributions to endoscopy, and is the foremost resource for endoscopic education. Visit www.asge.org and www.screen4coloncancer.org for more information and to find a qualified doctor in your area.

 

American Society for Gastrointestinal Endoscopy
3300 Woodcreek Drive Downers Grove, IL 60515
P (630) 573-0600
F (630) 963-8332
 www.asge.org
 www.screen4coloncancer.org

Media Contact

Andrea Lee
Director of Marketing and Communications
630.570.5603
ALee@asge.org