January 11, 2016

More than 14 million screening colonoscopies are performed each year.  Anesthesiologists and nurse anesthetists participate in a large proportion of these procedures.  There are several developments that may bring down the numbers or at least slow the rate of growth of screening colonoscopies that our readers, especially those whose practices include a significant volume of anesthesia for colonoscopy services, should note.

The first of the changes going forward is the reduction of Medicare payments for lower gastrointestinal endoscopies that went into effect on January 1, 2016.  CMS announced, in the Final Fee Schedule Rule issued in November 2015, that it was reducing the relative value units (RVUs) for the physician-work component of the Fee Schedule payment for screening colonoscopies by nine percent, from 3.69 to 3.36 RVUs, the value recommended by the AMA/Specialty Society Relative Value Update Committee (RUC). There were also changes to the RVUs for practice expenses. The resulting payment amounts and the decrease from 2015 to 2016 are shown below:

Source:  American Gastroenterological Association

The majority of endoscopic procedures are performed in “Facilities” (ASCs, certified endoscopy clinics and hospital outpatient departments) and not in private physicians’ offices, so the cut for most gastroenterologists will be on the order of 9.5 percent for screening colonoscopies alone.  The RVUs and hence the payment amounts for other lower GI endoscopies were reduced by as much as 17 percent.  The predictable response from the gastroenterologists’ associations, as reported in the CMS explanation of its decision, was:

Many commenters expressed concerns that the proposed values for the lower GI code set will hinder efforts to reduce the incidence of colorectal cancer through detection and treatment by limiting access to screenings.  Comments stated, “According to a poll of more than 550 gastroenterologists, more than half of the respondents plan to limit new Medicare patients if the proposed cuts are implemented; 55 percent plan to limit procedures to Medicare patients; and 15 percent are considering opting out of Medicare entirely.  These findings suggest that GI physicians may not be able to maintain the current mix of Medicare patients and protect the financial viability of their practices.”

Further reductions in payment will be introduced as early as 2017 if CMS follows through on its plans to remove the value of moderate sedation from the codes that currently include it, including most of the GI endoscopy codes. 

If the endoscopists reduce the number of screening colonoscopies that they perform on Medicare patients, there will be a concomitant decrease in the demand for anesthesia for these services.  There are anesthesia practices whose case mix consists predominantly of anesthesia for lower GI endoscopies and whose business plans might potentially be affected. 

Moreover, CMS has foreshadowed reductions in payments for anesthesia for colonoscopies.  In the Final Rule, CMS noted that a separate anesthesia service is now billed to Medicare in more than 50 percent of colonoscopies and announced that “Given the significant change in the relative frequency with which anesthesia codes are reported with colonoscopy services, we believe the relative values of the anesthesia services should be re-examined.”  The Agency plans to continue reviewing information, e.g., from the RUC, on whether anesthesia for upper and lower GI endoscopies is in fact “potentially misvalued.”

The ASA has vehemently protested CMS’s assumption that higher utilization levels means that CPT codes 00740 (anesthesia for upper GI endoscopy) and 00810 (lower GI endoscopy) are misvalued.  The change that took effect on January 1, 2015, waiving Medicare patients’ co-payments and deductibles for some screening colonoscopies is evidence that CMS understands the public health imperative of increasing the number of patients who seek screening.  (See ASA letter to CMS with “comments” on the proposal that was adopted in the Final Rule.)  Nonetheless, CMS is highly likely to proceed with determining new RVUs for the procedures, which might be in place as early as next year.

Only one in three patients between the ages of 50 to 75 has had any type of colorectal cancer screening, according to the Centers for Disease Control.  The need for more screening is clear—but non-invasive tests that do not require anesthesia may become more popular as more health insurers offer coverage.  Since October 2014 CMS has recognized stool-based DNA and fecal occult hemoglobin as covered services (as long as they are done by laboratories authorized by the manufacturer to perform the Cologuard™ test.) (See MLN Matters^®Number: MM9115.)  Although CMS does not currently cover computed tomography or “virtual” colonoscopies, that could change if a bill introduced in the U.S. Senate late last year—the "CT Colonography Screening for Colorectal Cancer Act of 2015,” S. 2262—were to be enacted into law. 

The bill’s chances for passage are slim in the near future; one reason is that the U.S. Preventive Services Task Force (USPSTF) does not recommend CT colonoscopies because of lack of evidence of effectiveness and concerns about radiation exposure and false positives.  The USPSTF guidelines do list virtual colonoscopies as an alternative screening option, however.  Cancer Therapy Advisor quotes Judy Yee, MD, chair of the American College of Radiology Colon Cancer Committee stating that "Cigna, United Healthcare, Anthem Blue Cross Blue Shield, and other major insurers cover screening virtual colonoscopy.  More than 20 states require insurers to cover these exams." 

The attraction of virtual colonoscopies and other non-invasive colorectal cancer screening tools is their relative lack of discomfort.  As the technologies improve and prove themselves, better insurance coverage will likely ensue.

In the shorter term, however, lower payment for colonoscopies may discourage enough gastroenterologists from performing these procedures on Medicare patients, which may in turn affect some anesthesia practices’ case mix and profitability.  Commercial health plans may follow CMS’s lead and reduce their payments in turn.  Representatives of the gastroenterology associations have pointed to such dire consequences as a shift of sites of service from efficient ASCs to less efficient hospital outpatient departments, practice mergers “to form supergroups that share operational costs,” “a massive migration from private practice into hospital employment/affiliation” and fewer new physicians choosing gastroenterology residencies.  (Pallardy C. GI Society Roundtable:  Putting Together the Game Plan for Potential Colonoscopy Cuts.  Becker’s GI & Endoscopy, July 31, 2015.)

With Medicare payments for anesthesia for screening colonoscopies also on the chopping block, some of our readers should think about evaluating the role and delivery of these services in their mid- to long-range planning.

With best wishes,

Tony Mira
President and CEO