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Released on Nov 1, 2019

CMS Finalizes 2020 Medicare Reimbursement Rules: What Is the Impact to GI Practices?

On November 1, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2020 final rules for the Physician Fee Schedule (PFS), Outpatient Prospective Payment System (OPPS) and Quality Payment Program, which include several significant policy and payment changes impacting gastroenterologists.

Here is a topline summary of the most important changes to the payment rates and policies for services paid under Medicare. 

Medicare PFS

CMS abandons proposed requirement forcing providers to give notice of post-polypectomy surprise billing. Under current law, Medicare beneficiaries are subject to cost-sharing when a screening colonoscopy turns therapeutic, but not when the procedure remains a “screening.” Resolving this coverage quirk has been a major policy initiative for the GI societies. In the past, CMS officials have concluded that the agency does not have the regulatory authority to fix this process, thus requiring a change in the law. In the Medicare PFS proposed rule, CMS sought feedback on whether providers should be required to notify patients of this potential problem prior to performing the screening. The GI societies pushed back and, based on our feedback, CMS decided not to move forward with the requirement.

Victory for GIs: Through a face-to-face meeting and in its comment letter, the GI societies urged CMS to abandon its proposal to require providers to notify Medicare beneficiaries about CMS coverage policy rules regarding CRC screening payment and, instead, fix this cost-sharing quirk via regulations or implore Congress to pass bipartisan legislation that deals with this problem if CMS does not have the regulatory authority to do so. CMS listened to us and will not require providers to notify Medicare beneficiaries of CMS’ payment policy on cost-sharing when polypectomy is performed during a screening colonoscopy. Instead, CMS will “undertake a comprehensive review of all of our outreach materials, such as the Medicare & You Handbook and Medicare Preventive Services, to see if Medicare policies on payment and coverage for screening colonoscopies can be made clearer. We believe this would be a service to Medicare beneficiaries.”

CMS finalizes plan to adopt E/M coding and reimbursement changes proposed by AMA beginning 2021: In the proposed rule, CMS reversed plans it released in the 2019 Medicare PFS rule to collapse evaluation and management (E/M) levels 2-4 for office/outpatient established and new patients to begin in CY 2021. Instead, CMS accepted a plan to align with recent changes laid out by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel, which retains five levels of coding for established patients, reduces the number of levels to four for new patients, and revises the code definitions. The CPT changes also revise the times and medical decision-making process for all of the codes and require performance of history and exam only as medically appropriate. The CPT code changes allow clinicians to choose the E/M visit level based on either medical decision making or time. CMS finalized this plan for implementation Jan. 1, 2021.

Welcomed news: The GI societies worked with the AMA and a coalition of specialty societies to get CMS to rethink collapsing payment for E/M code levels, and subsequently supported the AMA’s proposed E/M changes as they moved through the CPT and Relative Value Scale Update Committee (RUC) processes. In the 2020 Medicare PFS final rule, CMS finalized plans to adopt the AMA CPT changes and RUC valuations.

Slight increase in MPFS conversion factor: The CY 2020 PFS conversion factor was finalized at $36.09, a slight increase above the CY 2019 PFS conversion factor of $36.04.


CY 2020 Medicare reimbursement rates for common GI procedures
(national average)

CY 2020 Medicare fee-for-services payment chart for selected GI services 

Quality Payment Program

Key proposals finalized for 2020 performance year of the Quality Payment Program:

  • Increase Merit-based Incentive Payment System (MIPS) performance threshold from 30 points to 45 points.
  • Maintain the MIPS Quality performance category weight at 35 percent in 2020.
  • Maintain the Cost performance category weight at 15 percent in 2020.
  • Increase data completeness threshold for submitting quality data from 60 to 70 percent for Medicare Part B claims measures, QCDR measures, MIPS Clinical Quality Measures (CQMs), and eCQMs.
  • Increase threshold for the number of clinicians who complete or participate in the Improvement Activity performance category for group reporting from one to 50 percent. However, CMS modified its proposal so that each improvement activity can be performed by at least 50 percent of the NPIs billing under the group’s TIN during any continuous 90-day period instead of requiring clinicians to perform the same activity for the same continuous 90 days.

CMS RFI on new MIPS Value Pathway: The GI societies were joined by more than 2,000 commenters in response to CMS’ request for information on creating a new MIPS Value Pathway (MVP) aimed at simplifying the program and reducing participation burden. CMS has not yet made any proposals regarding participation in an MVP structure, and will continue to solicit feedback from the stakeholder community as it undertakes further rulemaking in this area. 

MIPS category performance weights (2019 vs. 2020)
CMS finalizes removal of Measure 343 from MIPS performance year 2020: CMS finalized its plan to remove Measure 343 (Screening Colonoscopy Adenoma Detection Rate), claiming that it does not account for variables which may influence adenoma detection rate and that, due to its construction, benchmarks calculated from this measure are misrepresented and do not align with MIPS scoring methodology. ACG, AGA, and ASGE strongly advocated for the adenoma detection rate (ADR) measure to be maintained in public reporting. The literature clearly supports driving improvement in each gastroenterologist's ADR as the mechanism to reduce colorectal cancer incidence and deaths. We are disappointed in this decision. Our societies support ADR’s continued utility as an outcome measure that is an essential part of competency in colonoscopy and quality improvement activities.
 

OPPS/ASC

Slight increase on OPPS and ASC conversion factors: CMS proposes updating both OPPS and ambulatory surgery center (ASC) payment rates by 2.7 percent. Last year, CMS finalized its proposal to apply the hospital market basket update to ASC payment system rates for an interim period of five years (CY 2019 through CY 2023). CMS is not proposing any changes to this policy. In this rule, our Societies would specifically like to highlight a 6 percent increase for ERCP facility payment. 


 

CY 2020 Medicare facility fees for common GI procedures
(national average)

CY 2020 HOPD Medicare facility fees for selected GI services. 
 
CY 2020 HOPD Medicare facility fees for the top 10 GI base and biopsy codes. 
 
CY 2020 ASC Medicare facility fees for selected GI services. 
 
CY 2020 ASC Medicare facility fees for the top 10 GI base and biopsy codes.
 

Next Steps

ACG, AGA and ASGE are currently reviewing the details of the final rules and will be providing joint comments for those items that necessitate further comment. We will keep you updated as we learn more.
 
 
 
 
 

 

Thank you for your time. Please contact your GI Society with any questions:

 
American College of Gastroenterology
(301) 263-9000
 
American Gastroenterological Association
(301) 654-2055
 
American Society for Gastrointestinal Endoscopy
(630) 573-0600


 

ACG, AGA and ASGE are committed to collaborate on issues of common interest to all members of the GI community, including public policy and regulatory challenges facing gastroenterologists. This message is being sent as a joint communication from the three societies and has been reviewed by each organization.

 
For more information: ACG websiteAGA website ASGE website