Coding & Reimbursement

Coding Resource Center

This resource center has been developed by the Reimbursement Committee to assist ASGE members in properly coding gastrointestinal endoscopy services. Here you will find coding tip sheets, coding updates and coding instructions.

Medicare Physician Payment

The Medicare physician payment fee 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 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 new Quality Payment Program. The physician payment fee schedule final rule is published in late fall. 

ASC Payment System

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). 

CPT and RUC Process

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.

Industry CPT Coding Assistance

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.

Telehealth and virtual services coding guide

The coding guide will help ensure you’re using the right codes and modifiers to maximize reimbursement for the telemedicine and remote services you provide. This two-page guide includes an “at-a-glance” table for coding telehealth, telephone E/M, virtual check-ins, eConsultations and online digital E/M and detailed coding guidance and Medicare reimbursement information.

Telehealth virtual physical exam tips

While documenting the physical exam in the patient’s medical record for a telehealth visit is no longer required for Medicare, it may still be necessary to perform a virtual physical exam for clinical care and some commercial payors still require it. This guide provides examples for conducting and documenting a GI-focused telehealth E/M physical exam.