Gastroenterology Coding Alert

2016 could also usher in advance care planning payments.

After a long interval, there was a big relief in store for all those practices expecting to see devastating conversion factor cuts that would impact their payments in the Medicare Physician Fee Schedule proposal. As per the new “doc fix” Medicare payment model that the HHS announced in January, you have been spared a 20-plus percent cut in January like in previous years—in fact, you’ll get your second scheduled 0.5 percent pay increase on Jan. 1 (the first increase kicked in on July 1).

“This is the first rule that CMS has done regarding physician fees since the repeal of the SGR that many of us have been working on for several years,” said CMS’s Sean Cavanaugh during a July 14 Open Door Forum.

On July 8, CMS released the proposed Medicare Physician Fee Schedule that it created for the 2016 payment year. Although you won’t face payment insecurity issues, you will see some changes—and whether they’re good or bad depends on your practice mix.

Gastroenterologists Could Take A Hit

Although most specialists will see reimbursement remain stable in 2016, gastroenterologists would take a five percent hit to their payments effective Jan. 1 if the proposal is finalized, due to adjustments in endoscopic lower GI procedures, including colonoscopies. 

Although CMS foresees the cuts impacting this specialty by just five percent, the actual damage could be higher, depending on the mix of services that your doctors perform. For instance, the proposed rule suggests that CMS would like to lower the work RVUs for code 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) to 3.59 from its current level of 4.43, resulting in a nearly 19 percent hit to this service.

CMS will be accepting comments on the payment adjustment to what the agency described as “misvalued codes,” but in the meantime, the gastroenterology associations are not taking the news lying down. “AGA, ACG and ASGE will fight these cuts,” the American Gastroenterological Association said in a July 9 news brief. “We are scheduled to meet with CMS leadership this month and are exploring every means to mitigate these cuts before they are finalized. Cuts of this magnitude could compromise the nation’s public health efforts to reduce colorectal cancer.” “The Digestive Health Physicians Association (DHPA) representing over 1,200 independent practicing gastroenterologists is similarly concerned and has begun engaging their Capitol Hill representatives to consider how the proposed cuts could affect their Medicare constituents’ access to a highly effective preventative health service,” adds Michael Weinstein, MD, Vice President of Capital Digestive Care.

Get Ready for Potential Incident to Adjustments

If you’ve got the incident to rules for Part B memorized, it could be time to commit a new set of regulations to memory. The proposal suggests changes to the incident to rules, which allow a non-physician practitioner (NPP) to bill under the doctor’s ID number and collect a full fee rather than submitting claims under the NPP’s number and collecting 15 percent less.

Current way: Right now if you bill incident to, any doctor in the office can be listed on the claim as the person providing direct supervision for the NPP who is performing the service. 

Proposed 2016 way: In the proposed fee schedule, CMS suggests only paying for incident to services if the doctor who bills for the incident to service is the same person directly supervising the care. 

“To be certain that the incident to services furnished to a beneficiary are in fact an integral, although incidental, part of the physician’s or other practitioner’s personal professional service that is billed to Medicare, we believe that the physician or other practitioner who bills for the incident to service must also be the physician or other practitioner who directly supervises the service,” CMS says in the proposed rule.

In addition, CMS is proposing that the person providing the incident to service does so in accordance with state law and is licensed to do it. The incident to provider also cannot have been excluded from any federal health care program or have had their enrollment revoked for any reason. In other words, just because the service is billed under a supervising doctor’s number doesn’t mean the performing NPP can be excluded from Medicare. 

Prepare to comment: You have until Sept. 8 to comment on any of the proposals listed above. To read the complete proposed fee schedule and learn how to comment, read the rule at https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-16875.pdf.