CMS Reimbursement Changes for GI Cases Are In. What Will It Cost Your Anesthesia Practice?

by | Jan 31, 2018

The Centers for Medicare & Medicaid Services (CMS) has made its final base unit value decisions for anesthesia codes for 2018.

Anesthesia for upper gastrointestinal endoscopic procedures and for lower intestinal endoscopic procedures will no longer pay five base units, respectively.  These codes (00740 and 00810) have been erased and replaced by five new codes, which are outlined in the table below:

00731 (Anesthesia for upper GI, not otherwise specified) 5 Base Units
00732 (Anesthesia for upper GI, ERCP) 6 Base Units
00811 (Anesthesia for lower GI, not otherwise specified) 4 Base Units
00812 (Anesthesia for screening colonoscopy) 3 Base Units
00813 (Anesthesia for upper and lower GI during the same session) 5 Base Units

Please note that the ASA in their 2018 Relative Value Guide differ in their base unit value. They have given the 00812 code a base unit value of 4. We advise our clients to look at their commercial contracts and see how this difference is addressed. Some commercial carrier contracts pay according to ASA guidelines while others follow CMS guidelines.

Anesthesia groups performing services at GI centers and hospitals where colonoscopies are performed will see modest impacts to generated revenue.  This reduction in revenue will be due to the Medicare and ASA reduction of base units for screening colonoscopies and other colonoscopy procedures.

Several anesthesia groups have reached out to us for help in light of these drastic changes. The impacts to one group providing services at one such rural facility that we have analyzed are illustrated below:
  • The facility performs about 1,000 GI cases per year.
  • Roughly 78% of the facility cases in 2017 were lower intestinal endoscopic procedures cases coded as 00810.
  • The remainder of the case load was upper gastrointestinal endoscopic procedures coded as 00740.
  • Of the 78% of the cases that were 00810, only 15% of those are upper and lower cases, or turn into more than a screening colonoscopy (codes 00811 or 00813).
  • Roughly 400 cases at this facility will see a RVU reduction of 2 base units per case (based on CMS Medicare reductions), which results in a loss of 800 billable units per year
  • The remaining 78% ~ 380 cases will have a smaller reduction in base units.
  • This estimate is based on a rural blended anesthesia conversion factor of $30 per RVU.
  • Payer mix is 60% government 40% commercial.

We created a graph to show the estimated revenue for these procedures for 2017 compared to the new base units in 2018 resulting in an estimated $32,000 decrease in anesthesia revenue:

As you can see, if your GI anesthesia practice is running on a tight margin, this reduction in revenue will be enough to significantly impact your bottom line. This impact will cause groups to seek methods to improve efficiency and reduce costs to cope with the revenue decreases. OR efficiency and block scheduling will face increased scrutiny as administrators attempt to maintain their profitability with less revenue.

If you would like to discuss how this change will affect revenues at your facility and what you can do to offset this decrease, please contact us.