What Anesthesia Practitioners Should Know About GI Procedures for 2017

SUMMARY Downward pressure on payment to endoscopists based on the 2017 Physician Fee Schedule final rule continues to raise questions about the viability of the symbiotic relationship between anesthesia providers and endoscopists. At the same time, though colonoscopy is still considered the gold standard, less invasive techniques for colorectal cancer screening, such as fecal immunochemical testing (FIT), are gaining acceptance. Anesthesia providers will want to consider these trends in their practice planning.

Over the past decade or so, endoscopy has become a significant line of business for most of the country's anesthesia practices. Much empirical evidence has supported the role of anesthesia in the endoscopy center. Outcomes are more consistent, patients are more comfortable and endoscopists can be more productive.

Despite, or perhaps because of these factors, there has been ongoing concern about the future of reimbursement for the anesthesia provider. A critical signal came from Medicare last year when the Centers for Medicare and Medicaid Services (CMS) agreed to waive co-payment and deductible responsibility for patients undergoing a screening colonoscopy. Increasingly, endoscopists are accepting and embracing the role of anesthesia in their centers. While the ASA codes for endoscopy continue to have the same basic value for all payers, there is downward pressure on payment to the endoscopist. This raises questions about the viability of what has become a symbiotic partnership.

The payment rate for diagnostic colonoscopy (CPT Code 45378) to the surgeon saw a 16.5 percent decline in 2017 from 2016 (see table below). Gastroenterologists also took a hit in significant reductions in payment rates for numerous other procedures.

Source: GI Endoscopy Coding and Reimbursement Guide, Cook Medical

Site-Neutral Policy

In addition, payments for "off-campus" (non-facility) hospital department services also will drop in 2017, in gastroenterology as well as other specialties. According to Section 603 of the Bipartisan Budget Act of 2015, beginning on January 1, 2017, items and services furnished in an off-campus provider-based department are no longer considered covered outpatient department services for purposes of payment through the Outpatient Prospective Payment System (OPPS). Instead, these items and services will be payable under the Medicare Part B Physician Fee Schedule. The Congressional Budget Office estimates a savings as a result of this change of approximately $9.3 billion over 10 years. The change translates into sizable payment reductions to gastroenterologists for many procedures.

Gastroenterologists who do not perform their own moderate (conscious) sedation will see still further payment reductions. Gastroenterologists who provide their own moderate sedation will not be impacted, but they must now report two codes instead of one—the procedure code and the moderate sedation code. However, those who use the services of anesthesia providers will see a reduction in physician work relative value units and office practice expense for most GI endoscopy procedures. These reductions could translate into reduced demand for anesthesia services.

In addition, "Gastroenterologists who use anesthesia professionals will see the value of the majority of all GI endoscopy procedures reduced by 0.10 relative value units (RVUs). The reduction is less onerous than the 0.22 RVUs recommended by the American Medical Association (AMA) Relative Value Update Committee (RUC) and the 0.25 RVUs finalized by CMS for all other specialties' procedures for which the value of moderate sedation is currently inherent to the procedure," an article at the American Gastroenterologists Association's website states.

As the AGA, American College of Gastroenterologists and American Society for Gastrointestinal Endoscopy noted in an in-depth analysis of the 2017 proposed Physician Fee Schedule:

In the CY 2015 PFS proposed rule, CMS noted that for endoscopic procedures, it appeared that anesthesia services were increasingly being separately reported, meaning that resource costs associated with sedation were no longer being incurred by the practitioner reporting the procedure. Subsequently, in the CY 2016 PFS proposed rule, CMS sought recommendations on approaches to address the appropriate valuation of moderate sedation related to the approximately 400 diagnostic and therapeutic procedures, including the majority of GI endoscopy procedures, for which the AMA CPT Editorial Panel had determined that moderate sedation was an inherent part of furnishing the service.

Code Values Preserved

On a more positive note, the values for anesthesia services provided in conjunction with upper and lower gastrointestinal procedures (CPT codes 00740 and 00810) have been preserved for the time being. These two codes had been identified as potentially misvalued and were the focus of an AMA/Specialty Society Relative Value Update Committee survey in 2016. The RUC review revealed concerns about the clinical scenarios used in the surveys. As a result, the RUC recommended that the codes be resurveyed using more appropriate vignettes and that CMS keep the current values on an interim basis. CMS maintained the current five base units for anesthesia for upper and lower GI endoscopy procedures in 2017. However, it plans to review the relative values for these anesthesia services in 2017.

In its official comment letter on the proposed rule, the American Society of Anesthesiologists stated: "We appreciate the agency's fair-minded proposal to maintain current value for codes 00740 and 00810 and will continue to work with CPT, the RUC and CMS to address concerns about the valuation of these anesthesia services."

As reimbursements for colonoscopies and other endoscopy procedures decline, less invasive techniques as potential alternatives to colonoscopy are also continuing to emerge. Although colonoscopy is still considered the gold standard for colorectal cancer screening in the United States, a new consensus statement by the U.S. Multi-Society Task Force on Colorectal Cancer as published in Gastroenterology offers "strong evidence that fecal immunochemical testing (FIT) is an excellent alternative," a recent Medscape article reports. In addition, the 2016 U.S. Preventive Services Task Force recommendations now include seven different screening strategies: colonoscopy, FIT for occult blood, gFOBT, sigmoidoscopy alone, sigmoidoscopy plus FIT, the FIT-DNA test and computed tomographic colonography.

We hope this information assists you with your planning for the short and long term. If you have any questions, please contact your client manager.

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With best wishes,

Tony Mira
President and CEO