Medicare Issues 2015 Final Rules for Hospital Outpatient, Ambulatory Surgical Center and Physician Payment GI and Pulmonary Endoscopy

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1 Medicare Issues 2015 Final Rules fr Hspital Outpatient, Ambulatry Surgical Center and Physician GI and Pulmnary Endscpy SUMMARY: On Octber 31, 2014, the Centers fr Medicare and Medicaid Services (CMS) released Calendar Year (CY) 2015 final plicy and payment rates fr Medicare s Hspital Outpatient Prspective System (HOPPS) and Ambulatry Surgical Centers (ASC). CMS als released the CY2015 final rule and payment rates fr the Physician Fee Schedule (PFS). The final plicies and payment rates are effective January 1, HOSPITAL OUTPATIENT FACILITY PAYMENT Overall, average rates fr utpatient services will increase by 2.2% in CY2015. rates fr the Ambulatry Classificatins (APCs) characterizing the majrity f GI Endscpy prcedures will increase frm 1%-34%, and payment rates fr APCs characterizing brnchscpy prcedures will increase 11%-13%. GI Endscpy ERCP payment will increase 1%. GI Stenting payment will increase 34%. EUS-FNA and Dilatin payment will increase 5%. Upper GI Endscpy with Bipsy payment will increase 11%. As a result f Bstn Scientific s advcacy effrts, including meeting with CMS, presenting t the APC Advisry Cmmittee and prviding data t supprt the GI specialty scieties effrts t d the same, the fllwing significant changes will be implemented in 2015: CMS has accepted Bstn Scientific s recmmendatin t reassign bth CPT cde (ERCP with stent placement) and CPT cde (ERCP with stent exchange) t the GI Stenting APC (APC 0384). These tw new cnslidated cdes, which were intrduced in 2014 t replace cdes an 43269, were assigned t the ERCP payment grup fr 2014, resulting in significant payment reductins fr hspitals. CMS decisin t implement ur recmmendatin will result in a payment increase f 64% fr ERCP with stent placement and ERCP with stent exchange (frm apprximately $1,934 in 2014 t $3,174 in 2015). CMS has als accepted Bstn Scientific s recmmendatin t reassign the tw new CPT cdes describing upper GI endscpy with endscpic mucsal resectin (EMR), and 43254, t a higher paying APC. This actin will result in a payment increase f 59% (frm $670 in 2014 t $1,064 in 2015) fr each upper GI EMR cde. Bstn Scientific Endscpy is grateful t the GI specialty scieties fr their supprt f these advcacy effrts. CMS finalized its prpsal t make APC 0384, GI Prcedures with Stent, a cmprehensive APC. This means that hspitals will n lnger be paid separately fr ther prcedures reprted tgether with GI stent prcedures, and they will n lnger receive separate payment fr multiple stent placements. These changes impact utpatient hspital payment, hwever they d nt impact physician payment fr the same services. After analyzing prcedure mix and payment data, HE&R feels that the 34% increase in payment fr the APC versus 2014 shuld, in mst cases, address cncerns regarding the change t a cmprehensive payment methdlgy. CPT Cpyright 2014 American Medical Assciatin. All rights reserved. CPT is a registered trademark f the American Medical Assciatin.

2 Pancreatic pseudcyst drainage with stent placement payment will increase 89%, as CMS decided t reassign the prcedure t a higher paying APC. New and revised lwer endscpy CPT Cdes that will be effective January 1, 2015 were, in large part, assigned t the apprpriate APC based n the methd f access (i.e., clnscpy, clnscpy thrugh stma, ilescpy and sigmidscpy). Hwever, as they did last year, CMS mved new cdes fr lwer endscpy with stent placement t the clnscpy, clnscpy with stma, ilescpy and sigmidscpy APCs. The result will be reductins in payment ranging frm 64%-67% fr the fllwing prcedures: Ilescpy, thrugh stma; with placement f endscpic stent (includes pre- and pst-dilatin and guide wire passage, when perfrmed); Clnscpy thrugh stma; with endscpic stent placement (including pre- and pst-dilatin and guide wire passage, when perfrmed); Sigmidscpy, flexible; with placement f endscpic stent (includes pre- and pst-dilatin and guide wire passage, when perfrmed); and Clnscpy, flexible; with endscpic stent placement (includes pre- and pst-dilatin and guide wire passage, when perfrmed). Bstn Scientific will seek the same type f crrectin successfully sught fr ERCP with stent placement and exchange fr these lwer GI stent prcedures. Pulmnary Endscpy rates fr the tw APCs characterizing utpatient brnchscpy prcedures including brnchial thermplasty and brnchscpic stent placement will increase 11%-13%. Fr mre details n 2015 HOPPS payment fr GI and pulmnary endscpy prcedures, please see Table 1. Other Significant HOPPS Plicy Changes f Interest t be Implemented in 2015 Cmprehensive APCs CMS finalized the implementatin f 25 Cmprehensive APCs t further effrts t pay prviders fr quality, nt quantity f care. A cmprehensive APC (c-apc) packages payments fr services and supplies related t the delivery f an episde f care rather than paying separately fr each individual service prvided during the episde. In CY2015, c-apcs will prvide a single all-inclusive payment fr the designated primary service with n additinal reimbursement fr adjunctive services and supplies used during the delivery f the primary service. APC 0384, GI Prcedures with Stents, is the nly c-apc impacting GI and pulmnary endscpy. New Clnscpy Quality Measure Delayed - CMS has decided t delay the implementatin f ne additinal quality measure (Facility7-Day Risk-Standardized Hspital Visit Rate after Outpatient Clnscpy) in the Hspital Outpatient Quality Reprting prgram. Data cllectin will nw begin in 2016 and impact payment determinatin fr CY 2018 and subsequent years. ASC FACILITY PAYMENT ASC facility payments fr the majrity f key GI endscpy prcedures will increase 4-10%. Bipsy prcedures: will increase 6-10%. Clnscpy (diagnstic and therapeutic): will increase 6%. Upper GI endscpy with balln dilatin: will increase 4%. Fr mre details n 2015 ASC facility payment fr GI endscpy prcedures, please see Table 2. New Clnscpy Quality Measure Delayed - As it did fr the hspital utpatient setting, CMS has decided t delay the implementatin ne additinal quality measure (ASC-12: Facility Seven-Day Risk-Standardized Hspital Visit Rate after Outpatient Clnscpy) in the ASC Quality Reprting prgram. Data cllectin will nw begin in 2016 and impact payment determinatin fr CY 2018 and subsequent years. See last page fr imprtant infrmatin abut the uses and limitatins f this dcument. CPT Cpyright 2014 American Medical Assciatin. All rights reserved. CPT is a registered trademark f the American Medical Assciatin. Page 2 f 6

3 PHYSICIAN PAYMENT GI Endscpy GI specialty scieties had been expecting majr reductins (as high as 15%-20%) in payment fr clnscpy prcedures in 2015 as a result f a multi-year revaluatin prcess. As a result f strng advcacy by the scieties and prviders, CMS has decided t delay any majr changes in physician payment fr lwer endscpy prcedures until 2016 t allw fr additinal analysis and input. This is a significant win fr gastrenterlgists. Nw that majr payment changes fr lwer endscpy prcedures will be delayed until 2016, verall physician payment fr the majrity f GI endscpy prcedures, excluding a pssible sustainable grwth rate (SGR) cut, will remain flat r decrease by 5%. Once again, Medicare has finalized a 20.9% cut in physician payment fr all specialties beginning April 1, 2015 due t the Sustainable Grwth Rate (SGR) requirement. SGR mandates that ttal payments t physicians cannt grw at a rate higher than the specified SGR fr a given year. Therefre, after all cdes have been valued, if estimated ttal payments exceed the SGR, Medicare is required t implement additinal payment cuts t keep ttal expenditures within the pre-established limit. In prir years, Cngress has taken actin t avert this large cut. While Cngress is likely t intervene prir t the expiratin f SGR with a patch t negate the impact f this prpsed cut, we anticipate that the debate t find a permanent SGR fix will cntinue as Cngress weighs the csts and benefits f implementing varius pssible lng term slutins. Pulmnary Endscpy Physician payment fr brnchscpy prcedures will decrease by apprximately 1% verall. Physician payment fr brnchial thermplasty will decrease by 2%. Physician payment fr brnchial stenting will decrease by 1%. Physician payment fr transbrnchial needle aspiratin bipsy (TBNA) will remain flat Physician payment fr endscpic brnchial ultrasund (EBUS) will remain flat. Fr mre details n 2015 physician payment fr GI and pulmnary endscpy prcedures, please see Table 3. Other Significant Physician Plicy and Changes Transitining t 0-day Glbal Cdes- Physician payments fr surgical prcedures ften include payment fr related services prvided befre and after the surgery. CMS believes that payment rates fr many f these surgical prcedures may be misvalued because they have nt been updated in many years. As a result, CMS is finalizing its prpsal t eliminate 10- and 90-day glbal perids fr surgical prcedures, beginning with 10-day glbal services in CY 2017 and fllwing with the 90-day glbal services in In the future, physician payment fr the surgical prcedures will be revalued, and prviders will need t bill separately fr ther related services. New prcedure fr cmmenting n the valuatin f new, revised r misvalued cdes t be implemented in CY CMS is finalizing a new prcess fr assigning payment fr new, revised r misvalued prcedure cdes (CPT) beginning in CY2016. In instances where these cdes are received frm the American Medical Assciatin (AMA) t late fr inclusin in the prpsed rule, final valuatin wuld be delayed. CMS plans t wrk with the AMA t ensure that new cdes are received in time t be published in the prpsed rule. Hwever, if that is nt pssible, interim status indicatrs and APC assignments wuld be established. This wuld encurage the AMA t wrk with CMS t crdinate release f new and revised cdes t prvide apprpriate cmment during the prpsed rulemaking calendar prir t finalizatin in the Final Rules fr OPPS and physicians. See last page fr imprtant infrmatin abut the uses and limitatins f this dcument. CPT Cpyright 2014 American Medical Assciatin. All rights reserved. CPT is a registered trademark f the American Medical Assciatin. Page 3 f 6

4 Bstn Scientific encurages GI practices and physicians t submit their cmments and/r cncerns related t these changes directly t CMS. Cmments may be submitted electrnically r by mail and must be received n later than 5 p.m. n December 30, Electrnic cmments n this regulatin can be submitted t: Please fllw the instructins under the submit a cmment tab. Written cmments can be sent t the fllwing address ONLY: Centers fr Medicare & Medicaid Services, Department f Health and Human Services, Attentin: CMS-1612-FC, P.O. Bx 8013, Baltimre, MD Yu may send written cmments via express r vernight mail t the fllwing address ONLY: Centers fr Medicare & Medicaid Services, Department f Health and Human Services, Attentin: CMS-1612-FC, Mail Stp C , 7500 Security Bulevard, Baltimre, MD ADDITIONAL CHANGES Medicare has decided t define screening clnscpy t include anesthesia s that beneficiaries d nt have t pay cinsurance n the anesthesia prtin f a screening clnscpy when furnished by an anesthesilgist. TABLE INDEX At the end f this dcument, the fllwing three tables list detailed changes fr select GI and pulmnary endscpy prcedures: Table 1: CY 2015 Hspital Outpatient Final Rates Table 2: CY 2015 ASC Final Rates Table 3: CY 2015 Final Physician Fee Schedule COMMENTS / QUESTIONS If yu have questins r wuld like additinal infrmatin, please cntact: Maria Stewart Directr Kelly Shriner Directr / Maria.Stewart@bsci.cm Kelly.Shriner@bsci.cm Ann Ry Senir Manager Sfia Faucher Manager Ann.Ry@bsci.cm Sfia.Faucher@bsci.cm Megan Braswell Senir Analyst, Endscpy Marcia Fti Analyst II, BT Megan.Braswell@bsci.cm Marcia.Fti@bsci.cm Bstn Scientific Endscpy ENDOreimbursement@bsci.cm Fin See last page fr imprtant infrmatin abut the uses and limitatins f this dcument. CPT Cpyright 2014 American Medical Assciatin. All rights reserved. CPT is a registered trademark f the American Medical Assciatin. Page 4 f 6

5 Appendix: Final CY2015 Hspital Outpatient, ASC and Physician Rate Tables Table 1: CY2015 HOSPITAL OUTPATIENT FACILITY PAYMENT* This table reprts the final CY2015 payment rates fr hspital utpatient services and the percent change frm 2014 fr select endscpy and brnchscpy prcedures. APC Descriptin FINAL 2014 FINAL 2015 % Change 2014 vs Level I Endscpy Lwer Airway $952 $1,055 11% 0141 Upper GI Endscpy $670 $745 11% 0142 Small Intestine Endscpy $837 $852 2% 0424 Level II Small Intestine Endscpy $1,233 $1,249 1% 0143 Lwer GI Endscpy $737 $790 7% 0146 Sigmidscpy, Level I $461 $494 7% 0147 Sigmidscpy, Level II $779 $827 6% 0151 ERCP $1,934 $1,952 1% 0158 Clrectal Cancer Screening: Clnscpy $647 $655 1% 0384 GI Stenting Prcedures $2,371 $3,174 34% 0415 Level II Endscpy Lwer Airway $2,000 $2,255 13% 0419 Level II Upper GI Prcedures $1,013 $1,065 5% 0422 Level III Upper GI Prcedures $1,969 $1,914-3% * Nte: There is a separate facility and physician payment fr utpatient hspital services. The values in this table refer t the utpatient hspital facility payment nly. Table 2: CY2015 ASC FACILITY PAYMENT** This table reprts the final CY2015 ASC payment rates and the percent change frm 2014 fr select endscpy and brnchscpy prcedures. FINAL 2014 FINAL 2015 CPT Cde Descriptin Brnchscpy with bipsy(s) $526 $578 10% Upper GI endscpy with bipsy $370 $409 10% Upper GI endscpy with balln dilatin f esphagus $560 $584 4% Diagnstic clnscpy $407 $433 6% Clnscpy with bipsy $407 $433 6% % Change 2014 vs Clnscpy with remval f tumr(s), plyp(s), r ther lesin(s) by ht bipsy frceps $407 $433 6% Clnscpy with remval f tumr(s), plyp(s), r ther lesin(s) by snare technique $407 $433 6% G0105 Clrectal screen; high risk individual $357 $359 0% ** Nte: There is a separate facility and physician payment fr ASC services. The values in this table refer t the ASC facility payment nly. See last page fr imprtant infrmatin abut the uses and limitatins f this dcument. CPT Cpyright 2014 American Medical Assciatin. All rights reserved. CPT is a registered trademark f the American Medical Assciatin. Page 5 f 6

6 Table 3: CY2015 PHYSICIAN PAYMENT*** This table reprts the final CY2015 physician payment rates and the percent change frm 2014 fr select endscpy and brnchscpy prcedures. Final rates calculated with current cnversin factr f $ effective thrugh March 31, Rates are subject t change April 1, 2015 due t the 21.2% SGR reductin that will mst likely be addressed by Cngress.) 2015 CPT Cde Prcedure FINAL 2014 MD FINAL 2015 MD Esphagscpy, flexible, transral; with endscpic mucsal resectin $253 $241-5% % Change 2014 vs Esphaggastrdudenscpy, flexible, transral; with endscpic mucsal resectin $291 $282-3% Upper GI Endscpy with bipsy $152 $151-1% Upper GI Endscpy with balln dilatin f esphagus $169 $169 0% Upper GI Endscpy with remval f tumr(s) by snare technique $216 $214-1% Upper GI Endscpy with cntrl f bleeding $221 $219-1% Esphaggastrdudenscpy, flexible, transral; with placement f endscpic stent (includes pre- and pst-dilatin and guide wire passage, when perfrmed) $241 $238-1% ERCP with sphinctertmy $390 $386-1% Endscpic retrgrade chlangipancreatgraphy (ERCP); with trans-endscpic balln dilatin f biliary/pancreatic duct(s) r f ampulla (sphincterplasty), including sphinctertmy, when perfrmed, each duct $413 $408-1% Endscpic retrgrade chlangipancreatgraphy (ERCP); with placement f endscpic stent int biliary r pancreatic duct, including pre- and pstdilatin and guide wire passage, when perfrmed, including sphinctertmy, when perfrmed, each stent $498 $492-1% Chlangiscpy $129 $127-1% Clnscpy with bipsy $265 $262-1% Clnscpy with remval f tumr(s) by snare technique $315 $311-1% NEW cde G6025 Clnscpy, flexible, prximal t splenic flexure; with transendscpic stent placement (includes predilatin) $354 $336-5% Brnchial Thermplasty: 1 lbe $218 $214-2% Brnchial Thermplasty: 2 r mre lbes $230 $224-2% EGD EUS FNA $280 $277-1% G0105 Clrectal cancer screening; clnscpy n individual at high risk $222 $208-6% G0121 Clrectal cancer screening; nt high risk $222 $208-6% CPT Disclaimer: CPT Cpyright 2014 American Medical Assciatin. All rights reserved. CPT is a registered trademark f the American Medical Assciatin. Applicable FARS/DFARS Restrictins Apply t Gvernment Use. Fee schedules, relative value units, cnversin factrs, and/r related cmpnents are nt assigned by the AMA, are nt part f CPT, and the AMA is nt recmmending their use. The AMA des nt directly r indirectly practice medicine r dispense medical services. The AMA assumes n liability fr data cntained r nt cntained herein Bstn Scientific Crpratin r its affiliates. All Rights Reserved. Trademarks are the prperty f their respective wners. See last page fr imprtant infrmatin abut the uses and limitatins f this dcument. CPT Cpyright 2014 American Medical Assciatin. All rights reserved. CPT is a registered trademark f the American Medical Assciatin. Page 6 f 6