Gastroenterology 2014;146:849–853

AGA SECTION A Bundled Payment Framework for Colonoscopy Performed for Colorectal Cancer Screening or Surveillance Joel V. Brill,1 Rajeev Jain,2 Peter S. Margolis,3 Lawrence R. Kosinski,4 Worthe S. Holt Jr.,5 Scott R. Ketover,6 Lawrence S. Kim,7 Laura E. Clote,8 and John I. Allen9 Predictive Health, LLC, Paradise Valley, Arizona; 2Texas Digestive Disease Consultants, Dallas, Texas; 3University Gastroenterology, Providence, Rhode Island; 4Illinois Gastroenterology Group, Elgin, Illinois; 5Humana, Inc, Louisville, Kentucky; 6Minnesota Gastroenterology, PA, Saint Paul, Minnesota; 7South Denver Gastroenterology, PC, Englewood, Colorado; 8American Gastroenterological Association, Bethesda, Maryland; and 9Yale University School of Medicine, New Haven, Connecticut

W

ith the release of the 2014 Physician Fee Schedule by the Centers for Medicare & Medicaid Services (CMS), it is clear that the substantial reductions in reimbursement for endoscopic procedures will have a profound impact on the practice of community and academic gastroenterology.1 In the Final Rule, CMS rejected the recommendations of the American Medical Association/Specialty Society Relative Value Update Committee, establishing significant reductions in physician payment for esophagoscopy, esophagogastroduodenoscopy, endoscopic retrograde cholangiopancreatography, and endoscopic ultrasonography services by reducing the physician work component of the relative value units for many of the listed services. For some procedures, there was a reduction in relative value units of more than 30%. Future reductions in actual payment to physician practices may occur if the conversion factor (dollars paid per relative value units) is adjusted further. Implementation of these changes by Medicare could potentially result in an $80 million reduction in 2014 payments for endoscopic services based on 2011 Medicare claims paid for these procedures, which does not take into account the impact on commercial payers who base their fee schedules on a percentage of Medicare. Further revisions by CMS to payment for colonoscopy, enteroscopy, and flexible sigmoidoscopy procedures are poised to occur in 2015. Reductions in fee-for-service (FFS) payments are occurring concurrently with payers and purchasers considering fundamentally different payment models for health care professionals, facilities, clinical laboratories, and other providers in light of the larger national spotlight on the Patient Protection and Affordable Care Act. This act, which was signed into law in March 2010, has provisions that focus on developing payment changes to curb overall health care cost growth and improve the quality of care delivered to patients.2 Over the past 20 years, health care costs have increased at nearly twice the rate of annual inflation. Tempering enthusiasm for efforts to pay for performance is the realization that FFS payment models, incentive programs, and registries have not helped physicians demonstrate value and differentiate their practice from others.3,4 With health care expenditures projected to account for nearly 20% of the federal budget by the end of

this decade,5 it is no surprise that policymakers are exploring alternative payment models that shift from FFS to value-based reimbursement for many health care services.6 Alternative payment models focus on the value of care delivered, as measured by health outcomes (quality) per dollar expended (cost). These models link quality to efficiency and may have providers share financial risk for patients’ health outcomes. Examples include reference pricing for services for which there is little variation in quality or sufficient quality data to help determine which providers are high value, not just low cost,7,8 “bundled payments” to health care providers that are related to the predetermined expected costs of a grouping or “bundle” of related health care services,9,10 payments for episodes of care,11 and payments to provider organizations (including physician groups, networks, and health systems) to assume risk for a defined population.12,13 In 2009, the American Gastroenterological Association Institute (AGA) Governing Board anticipated migration to alternative payment models and committed resources to help educate members. Since then, the AGA has developed a portfolio of practice tools to help members thrive in the storm of health care reform. The “Roadmap to the Future of GI Practice” contains a number of tools to aid practices in adapting to the changing business environment.14,15 One tool in the roadmap portfolio is a framework for practices to understand and negotiate reimbursement for a “colonoscopy bundle” for screening and surveillance examinations. Recognizing the potential advantages of bundled payment models, the AGA convened a work group of practicing clinicians and content experts in 2012 to develop a framework that could define a bundle in a gastroenterology practice. The work group explored various gastrointestinal services and procedures, such as inflammatory bowel

Abbreviations used in this paper: AGA, American Gastroenterological Association Institute; CMS, Centers for Medicare & Medicaid Services; CRC, colorectal cancer; FFS, fee-for-service. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.01.043

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disease, gastroesophageal reflux disease, and services related to gastrointestinal cancers, and spoke with numerous stakeholders, including providers, purchasers, government representatives, and payers. Based on their research, the work group recommended that the AGA initially focus on developing a bundle for colorectal cancer (CRC) screening and surveillance. The decision to focus on this topic was based on several factors. As recent criticism in the news media has revealed, CRC screening and surveillance is not a well-standardized procedure; significant regional variations in site of service, preparation agent, sedation methodology, and surveillance follow-up intervals show that opportunities to improve the quality and cost of care provided are both necessary and plentiful.16–19 As noted in the preceding text, reimbursement for endoscopy services is under attack, with the significant likelihood that CMS will reduce reimbursement for colonoscopy in 2015. Thus, negotiating a bundled payment for colonoscopy services provides physicians with the potential to secure favorable reimbursement in advance of possible cuts in reimbursement in the future. In 2013, the National Commission on Physician Payment Reform identified alternatives to FFS payment, noting “A distinguishing factor of fixed payment is that physicians may bear some or all of the financial risk of patient care, that is, they may either share in the savings as compared to historical charges or market rates, or bear part or all of the increased cost.”20 One of the models identified is bundled payments, where Under this payment mechanism, a fixed price is paid in return for care related to a specific condition, event, or episode such as a hip replacement or a heart attack. Similar to diagnostic-related groups that Medicare uses to pay hospitals, this payment mechanism should encourage better coordination within physician teams and among physicians, hospitals, and others involved in patient care. With a fixed price for the total episode, physicians have a financial incentive to be more prudent than they would under fee-for-service. However, bundled payment faces a number of practical difficulties: defining what is in the bundle; finding ways to divide payment among participating physicians; determining what to do when some physicians involved in the care do not share in the bundled payment; and factoring in the health status of patients (risk-adjustment).20

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Similar to successful bundled payment models developed in cardiology and orthopedic surgery specialties,21,22 colonoscopy for CRC screening and surveillance is a definable episode with a clear “beginning” and “end” point. A narrow and more predictable range of expected services helps to limit variability in costs for both payers and providers. A colonoscopy bundle contains medical services that are included in a usual CRC prevention paradigm whether colonoscopy is used as the initial screening tool, as a diagnostic test for another positive screen, or for surveillance. The bundle includes potential complications, allowing some practices to negotiate a procedural warranty if desired. In this framework, a practice can develop its own negotiation

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strategy with purchasers and payers with the assurance that the framework had expert input and real-world application. Although still a form of FFS, bundled payments aim to facilitate financial alignment and coordination among providers. Instead of being paid piecemeal for each service provided and being rewarded for the quantity of services billed, providers are rewarded for identifying gains in efficiency, effectively coordinating patient care, and improving the quality of care provided. Whereas FFS rewards providers for providing fragmented care to sick patients, bundled payment models reward providers for providing coordinated care (the right care, in the right place, at the right time) to patients with an incentive to assist patients in remaining healthy (ie, not in need of additional medical services). A bundled payment linked to outcome measurement can then serve to reduce unnecessary costs while maintaining or improving the quality of care. The AGA physician work group developed a bundled payment framework (see Appendix) for selected colonoscopy services, restricted to the following procedures:
Screening: Colonoscopy performed as a preventive service in an asymptomatic patient who is being screened for CRC
Diagnostic: Colonoscopy performed as a diagnostic service in a patient who has undergone screening for CRC with another test (eg, fecal occult blood test, fecal immunochemical test, stool DNA, blood test, flexible sigmoidoscopy, computed tomographic colonography, and so on) and was found to have an abnormality that warrants referral for colonoscopy
Surveillance: Colonoscopy performed in a patient who has previously undergone CRC screening and is now returning for follow-up colonoscopy, including patients who B

Had a previous negative screening colonoscopy

B

Had a previous colonoscopy in which precancerous polyps were identified

B

Had resection of colon/rectal cancer

B

Are being treated with pharmaceuticals where there is an increased risk of development of preneoplastic lesions in the colon.


Exclusions: B

Therapeutic procedures -

Evaluation of bleeding (except postpolypectomy)

-

Removal of a foreign body

-

Evaluation of abdominal pain

-

Dilation of stricture

-

Placement of stent

-

Decompression

-

Endoscopic mucosal resection of large lesions

-

Endoscopic ultrasonography

B

Pediatric patients (younger than 18 years)

B

Asymptomatic patients with potential premalignant conditions

B

-

Lynch syndrome (hereditary nonpolyposis colorectal cancer)

-

Familial adenomatous polyposis

-

Peutz–Jeghers syndrome

-

Inflammatory bowel disease requiring surveillance 4-quadrant biopsies every 10 cm

Other defined high-risk conditions not listed in the preceding text

The work group defined 3 components of the framework: 1. The preprocedure period, which includes services performed before screening colonoscopy, such as physician/staff consultation, bowel preparation, and instructions. Recognizing that colonoscopy is a surgical procedure, the clinicians emphasized the need for patients to have an office visit and/or to provide a complete and accurate history before the procedure to assess the patient’s health status and emphasize excellent bowel preparation. 2. The procedure period (1 day), which includes billed services incurred on the day of colonoscopy (eg, facility, professional fee for colonoscopy, sedation, pathology, and intraprocedure devices to improve the adequacy of bowel preparation). 3. The postprocedure period, which includes postprocedure follow-up and communication with patients, repeat colonoscopies because of postprocedure (polypectomy) bleeding, and repeat colonoscopies because of poor preparation or inadequate visualization of the lumen. Noting that the goal of a colonoscopy procedure is to provide a high-quality, complete visualization to the cecum (or small bowel–colon anastomosis) and to make evidencebased recommendations for surveillance intervals based on the findings, the work group believed it was important for the endoscopist to complete the examination while assuming the risk of having patients return because of poor bowel preparation. The work group also noted that when technical difficulties lead to an incomplete procedure or a large polyp requires special expertise or technique for removal, choosing to repeat a colonoscopy versus referral for computed tomographic colonography, barium enema, or colon capsule services should be defined and factored into the bundled payment. The postprocedure period would include professional charges by the endoscopist or partners incurred from complications directly related to the index colonoscopy procedure and occurring within 7 days of the procedure, such as postpolypectomy bleeding. The work group believed it was important for the endoscopist to assume the risk of getting it right the first time and not

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rewarding physicians for having patients return a second or even a third time because of poor bowel preparation, so the recommendation was that the postprocedure period be expanded to 1 year for repeat examinations due to poor preparation or incomplete procedures. For the postprocedure period, the work group found it necessary to understand the incidence of repeat procedures and postprocedure complications, because such data are required for the physician to calculate actuarial risk and hence a negotiated reimbursement. To obtain these data, the AGA presented the bundle concept to the CMS Innovation Center, several regional and commercial payers, McKesson, Brookings Institute, and the Health Care Incentives Improvement Institute. Humana, a national payer with commercial, Medicare, Tricare, and Medicaid lines of business, graciously provided the AGA with a de-identified patient claims data set covering commercial and Medicare patients and provided technical and clinical assistance in analyzing the data regarding the postprocedure period. McKesson collaborated with the AGA to develop a claims payment logic that enables bundled payment and allows payers to determine when claims submitted from a health care professional should be included in the bundle.23 The Health Care Incentives Improvement Institute provided clinical and technical support; reviewed postprocedure diagnoses and complications against their Evidence-Informed Case Rate model24,25; set the stage for incorporating the colonoscopy bundle into a Bridges to Excellence recognition program focused on CRC screening, prevention, and surveillance; and introduced the bundle to clinicians and payers to pilot test. The model as described can serve as a framework for a bundled payment that could be applicable to gastroenterologists who wish to contract with health plans, marketplaces, employers, purchasers, and accountable care organizations. In defining a framework and educating gastroenterologists about value-based reimbursement, the AGA is not aiming to mandate implementation of alternative payment models or propose a specific payment for colonoscopy. Interested practices should note that there is risk associated with a bundle model. Practices should analyze their existing data to determine the frequency of incomplete procedures and poor bowel preparations so they can factor this information into a proposed payment. For example, if the practice has a 3% rate of incomplete procedures, the cost of 3 alternative procedures to complete the evaluation of the colon (computed tomographic colonography, barium enema, or capsule endoscopy) could be amortized into the bundled payment. Practices that perform procedures in high-quality cost-efficient settings will be rewarded, and practices can use a bundled payment as a mechanism for negotiation and alignment with health care systems. As noted in the preceding text, practices should ensure that contracting plans can adjudicate claims accurately in the negotiated bundle. All gastroenterologists want to provide care that is safe, effective, and appreciated by patients and payers. Because there have been calls by researchers,26–28 specialty organizations,29 business coalitions,30 and consumer and

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purchaser31–33 entities for a “colonoscopy quality index” that assures the patient of the completeness and quality of the procedure, suggesting that patients and purchasers are demanding objective measures of the value of care they receive, physicians should anticipate the need to benchmark and report on the quality of colonoscopy using a qualified clinical data registry or the AGA’s Digestive Health Recognition Program as preparation for public reporting of clinical (and ultimately cost) data. We now face the additional burden of having to measure our performance, relate those metrics to per unit costs, and hence derive a defined “value” of our services.34,35 Physicians who cannot quantify costs, appropriateness, and health outcomes for colonoscopy could see a negative impact on practice revenue.36 Transparency of cost and quality is now expected by referring clinicians, health care systems, and patients.37–39 The AGA will continue to develop tools that forwardthinking practices can use as they travel the road ahead. Health care reform 3.0 is beginning and will be characterized by increasing cost containment and demands for quality measurement.40 Although some have questioned cost variation in the performance of colonoscopy, gastroenterologists understand the value of this procedure for individual patients and improving the public health of this nation.41

Supplementary Material Note: To access the full bundled payment framework model accompanying this article, visit the online version of Gastroenterology at www.gastrojournal.org, and at http:// dx.doi.org/10.1053/j.gastro.2014.01.043.

References

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1. 42 CFR Parts 405, 410, 411, et al. Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, Clinical Laboratory Fee Schedule & Other Revisions to Part B for CY 2014; Final Rule 78 FR 74230–74823. 2. The Patient Protection and Affordable Care Act (P.L. 111–148) and the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152). 3. Berenson RA, Kaye DR. Grading a physician’s value- the misapplication of performance measurement. N Engl J Med 2013;369:2079–2081. 4. Rosenthal E. The $2.7 trillion medical bill. Colonoscopies explain why U.S. leads the world in health expenditures. The New York Times June 1, 2013:A1. 5. Cuckler GA, Sisko AM, Keehan SP, et al. National health expenditure projections, 2012–22: slow growth until coverage expands and economy improves. Health Aff 2013;32:1820–1831. 6. Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Cambridge, MA: Harvard Business School Press; 2006. 7. Robinson JC, MacPherson K. Payers test reference pricing and centers of excellence to steer patients to lowprice and high-quality providers. Health Aff 2012;31: 2028–2036.

Gastroenterology Vol. 146, No. 3 8. Reinhardt UW. The sleeper in health care payment reform. New York Times August 2, 2013. 9. Ahlquist GD, Javanmardian M, Saxena SB. Healthcare shifts from à la carte to prix fixe. StrategyþBusiness November 12, 2013. 10. Vesely R. An ACE in the deck? Bundled-payment demo shows returns for hospitals, physicians, patients. Modern Healthcare. February 7, 2011. 11. Hussey PS, Sorbero ME, Mehrotra A, et al. Episodebased performance measurement and payment: making it a reality. Health Aff 2009;28:1406–1417. 12. Delbanco SF, Anderson KM, Major CE, et al. Promising payment reform: risk-sharing with accountable care organizations. The Commonwealth Fund, July 2011. 13. Paulus RA, Davis K, Steele GD. Continuous innovation in health care: implications of the Geisinger experience. Health Aff 2008;27:1235–1245. 14. Allen JA. The road ahead. Clin Gastroenterol Hepatol 2012;10:692–696. 15. American Gastroenterological Association. Roadmap to the future of GI. Available at: http://www.gastro.org/ practice/roadmap-to-the-future-of-gi. 16. Stock C, Hoffmeister M, Birkner B, et al. Inter-physician variation in follow-up colonoscopies after screening colonoscopy. PLoS One 2013;8:e69312. 17. Saini SD, Nayak RS, Kuhn L, et al. Why don’t gastroenterologists follow colon polyp surveillance guidelines? Results of a national survey. J Clin Gastroenterol 2009; 43:554–558. 18. Goodwin JS, Singh A, Reddy N, et al. Overuse of screening colonoscopy in the Medicare population. Arch Intern Med 2011;171:1335–1343. 19. Ko CW, Dominitz JA, Green P, et al. Utilization and predictors of early repeat colonoscopy in Medicare beneficiaries. Am J Gastroenterol 2010;105:2670–2679. 20. Frist W, Schroeder S, Bigby J, et al. Report of the National Commission on Physician Payment Reform. Washington, DC: National Commission on Physician Payment Reform, March 2013. 21. Cooley DA, Adams JW. Package pricing at the Texas Heart Institute. Consumer-driven health care: implications for providers, payers and policymakers. San Francisco, CA: Jossey-Bass, 2004:612–619. 22. Robinson JC, Brown TT. Increases in consumer cost sharing redirect patient volumes and reduce hospital prices for orthopedic surgery. Health Aff 2013;32: 1392–1397. 23. Moeller D. Building your automated bundled payment for an episode-of-care initiative. Am Health Drug Benefits 2011;4:403–405. 24. de Brantes F, Camillus JA. Evidence-informed case rates: a new health care payment model. New York, NY: Commonwealth Fund, 2007. 25. Mechanic RE, Altman SH. Payment reform options: episode payment is a good place to start. Health Aff 2009;28:262–271. 26. Baxter NN, Sutradhar R, Forbes SS, et al. Analysis of administrative data finds endoscopist quality measures associated with postcolonoscopy colorectal cancer. Gastroenterology 2011;140:65–72.

27. Lieberman DA, Nadel M, Smith RA, et al. Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable. Gastrointest Endosc 2007;65:757–766. 28. Lieberman DA, Faigel DO, Logan JR, et al. Assessment of the quality of colonoscopy reports: results from a multicenter consortium. Gastrointest Endosc 2009;69: 645–653. 29. Rex DK, Petrini JL, Baron TH, et al. ASGE/ACG Taskforce on Quality in Endoscopy. Quality indicators for colonoscopy. Am J Gastroenterol 2006;101:873–885. 30. Amundsen G. Individual physician colonoscopy quality reporting. Peoria, IL: Quality Quest for Health, February 2013. 31. National Colorectal Cancer Roundtable. November 2013. Available at: http://nccrt.org/about/quality/accreditationprogram. 32. Fennerty MB. Quality colonoscopy: how do you let your patients know you meet the mark? NEJM Journal Watch December 30, 2012. 33. Burstin H. Consensus Standards Approval Committee: memo on colonoscopy quality index measure review. Washington, DC: National Quality Forum, July 2, 2013. 34. Qaseem A, Alguire P, Dallas P, et al. Appropriate use of screening and diagnostic tests to foster high-value, costconscious care. Ann Intern Med 2012;156:147–149. 35. Owens DK, Qaseem A, Chou R, et al. Clinical Guidelines Committee of the American College of Physicians. Highvalue, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions. Ann Intern Med 2011;154:174–180.

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36. McMahon LF, Chopra V. Health care cost and value: the way forward. JAMA 2012;307:671–672. 37. Sinaiko AD, Rosenthal MB. Increased price transparency in health care—challenges and potential effects. N Engl J Med 2011;364:891–894. 38. Hibbard JH, Greene J, Sofaer S, et al. An experiment shows that a well-designed report on costs and quality can help consumers choose high-value health care. Health Aff 2012;31:560–568. 39. Haviland AM, Sood N, McDevitt R, et al. The effects of consumer-direct health plans on episodes of health care. Forum Health Econ Policy 2011;14:1–27. 40. Allen JI. Health care reform 3.0: the road gets bumpy. Clin Gastroenterol Hepatol 2013;11:1527–1528. 41. Allen JI. The value of colonoscopy. Gastroenterology 2014;146:573–575.

Reprint requests Address requests for reprints to: American Gastroenterological Association, 4930 Del Ray Avenue, Bethesda, MD 20814. e-mail: [email protected]. Acknowledgments The AGA thanks Olga Koronkevitch, Ross Lagerblade (Humana), Fredrik Tolin, MD (CoventryCares of Kentucky), Douglas Moeller, MD (McKesson), John O’Shea, MD, Sarah Bleiberg, Kavita Patel, MD, MS (Brookings Institute), Amita Rastogi, MD, Sarah Burstein, Francois deBrantes (Health Care Incentives Improvement Institute), and Kathleen Mueller (AskMueller Consulting, LLC) for technical assistance. Conflicts of interest All authors were required to complete a disclosure statement. These statements are maintained at the AGA headquarters in Bethesda, Maryland, and pertinent disclosures are published with the report. Dr Holt is a vice president at Humana, Inc.

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Appendix

Preoperative Services (3 Days)

The AGA has developed a bundle for colonoscopy services performed for the following indications:

1. Preprocedure evaluation


A preventive service for an asymptomatic patient who is being screened for CRC
A diagnostic service for an asymptomatic patient who has undergone screening for CRC (eg, fecal occult blood test, fecal immunochemical test, stool DNA, blood test, barium enema, flexible sigmoidoscopy, computed tomographic colonography, colon capsule) and was found to have an abnormality that warrants referral for a procedural colonoscopy
A surveillance service for a patient who has previously undergone CRC screening and is now returning for follow-up colonoscopy in accordance with the guidelines for colonoscopy surveillance after screening and polypectomy from the US Multi-Society Task Force on Colorectal Cancer1
Includes the following: B B

Surveillance after resection of colon2/rectal3 cancer Surveillance of asymptomatic patients who are being treated with pharmaceuticals resulting in an increased risk of development of colonic preneoplastic lesions (eg, teduglutide).

Population exclusions include the following:
Therapeutic colonoscopy (eg, evaluation of bleeding [except postpolypectomy], removal of a foreign body, evaluation of abdominal pain, dilation of stricture, placement of stent, decompression, endoscopic mucosal resection, endoscopic ultrasonography) B

Current Procedural Terminology (CPT) codes 44390, 44391 (except postpolypectomy bleed), 44397, 45379

B

CPT codes 45382 (except postpolypectomy bleed), 45386, 45387, 45391, 45392


Pediatric patients (younger than 18 years)
Asymptomatic patients with a history of the following premalignant conditions: B

Lynch syndrome (hereditary nonpolyposis colorectal cancer)

B

Familial adenomatous polyposis

B

Peutz–Jeghers syndrome

B

Inflammatory bowel disease requiring 4-quadrant biopsies every 10 cm.4


Other defined high-risk conditions.

a. CPT code 99201–99205 (new patient, office) b. CPT code 99211–99215 (existing patient, office) c. CPT code 99241–99245 (consultation, office, nonMedicare) d. CPT codes 99395–99397 (preventive medicine reevaluation) e. CPT codes 99401–99404 (preventive medicine counseling, individual) f. CPT codes 99411–99412 (preventive medicine counseling, group) g. CPT codes 99487–99489 (complex chronic care management) 2. Preparation a. Bowel cleansing agents 3. Prophylactic antibiotics 4. Preprocedure blood tests (if required by facility) a. Prothrombin time, partial thromboplastin time, international normalized ratio, complete blood count, chemistry panel

Colonoscopy (1 Day) 1. Facility fee a. Ambulatory surgical center fee b. Hospital outpatient department fee c. Nonfacility site-of-service differential i. Healthcare Common Procedure Coding System code A4550 (surgical tray)a 2. Professional fee for colonoscopy a. CPT codes 45378, 45380, 45381, 45383, 45384, 45385, G0105, G0121 b. CPT codes 44388, 44389, 44392, 44393, 44394 3. Sedation fee a. Monitored anesthesia care services provided by anesthesiologist or nurse anesthetist i. CPT code 00810b including the following: 1. Physical Status Modifiers P3c, P4d, or P5e

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2. code 99100 (add-on code for patients older than 70 years)

ii. CPT codes 99441–99443 (5–10 minutes of discussion via telephone)a

3. code 99135 (add-on code for utilization of controlled hypotension)

iii. CPT code 99444 (online E/M service)a iv. CPT codes 99281–99285 (emergency department visit)

b. Pharmaceuticals for sedation i. Midazolam, meperidine, fentanyl, propofol, and so on

v. CPT codes 99366–99386 (medical team conference)

c. Computer-assisted moderate sedation

vi. CPT codes 99487–99489 (complex chronic care coordination services)

d. Moderate sedation i. CPT codes 99143–99150 4. Biopsy fee for pathology specimens a. CPT code 88304, 88305, 88306 b. Special stains 88312, 88313, 88314, 88319 5. Intraprocedure devices a. Devices for cleaning/washing bowel lumen b. Devices for visualization: high definition, retrovision scopes, and so on a

Not covered by Medicare. There are 5 base units, with 1 unit for each 15 minutes of service. CMS data indicate that w8.3 units are billed on average. c The patient has some functional limitations, including a controlled disease of more than one body system or one major system; no immediate danger of death; controlled congestive heart failure, stable angina, previous myocardial infarction, poorly controlled hypertension, morbid obesity, or chronic renal failure; or bronchospastic disease with intermittent symptoms. d The patient has at least one severe disease that is poorly controlled or at end stage; possible risk of death; or unstable angina, symptomatic chronic obstructive pulmonary disease, symptomatic congestive heart failure, or hepatorenal failure. e The patient is not expected to survive more than 24 hours without surgery; has an imminent risk of death; or has multiorgan failure, sepsis syndrome with hemodynamic instability, hypothermia, or poorly controlled coagulopathy. b

2. General exclusions a. E/M services provided by the patient’s primary care physician/qualified health care professional b. Emergency department services provided by a physician/qualified health care professional outside of the endoscopist’s TIN c. Surgical services (includes E/M and procedural) to treat a complication of colonoscopy (other than postpolypectomy bleeding) d. Anesthesiologist services to treat a complication of colonoscopy (other than postpolypectomy bleeding) that warrants surgical intervention e. Anatomic pathology services incurred to treat a complication of colonoscopy (other than postpolypectomy bleeding) f. All other services not specifically enumerated under 1–3 3. General inclusions a. Repeat colonoscopy due to poor preparation/inadequate visualization of lumenb b. Repeat colonoscopy due to incomplete procedureb c. Follow-up computed tomographic colonography/barium enema/colon capsule due to incomplete procedure; includes professional and technical feesb d. Repeat colonoscopy for postpolypectomy bleeding that occurs within 7 days after the index procedurec a

Not covered by Medicare. Performed by the same or a different endoscopist within 1 year of the index procedure. c Performed by the same or a different endoscopist within 48 hours of the index procedure. b

Postoperative Interval (7 Days) 1. Postprocedure evaluation/management follow-up a. Services performed by an endoscopist (includes other physicians and qualified health care professionals [physician assistant, nurse practitioner] who bill under the same TIN) i. CPT code 99212–99215 (E/M office or other outpatient visit)

References 1. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143:844–857.

853.e3 Brill et al 2. Rex DK, Cahi CJ, Levin B, et al. Guidelines for colonoscopy surveillance after cancer resection: a consensus update by the American Cancer Society and the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2006;130:1865–1871. 3. Anthony T, Simmang C, Hyman N, et al. Practice parameters for the surveillance and follow-up of patients

Gastroenterology Vol. 146, No. 3 with colon and rectal cancer. Dis Colon Rectum 2004; 47:807–817. 4. Lieberman DA, Nadel M, Smith RA, et al. Standardized colonoscopy reporting and data system: report of the Quality Assurance Task Group of the National Colorectal Cancer Roundtable. Gastrointest Endosc 2007;65: 757–766.

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Outpatient Inclusions

ICD-9

ICD-9 descriptor

578.9 Hemorrhage of gastrointestinal tract, unspecified 560.81 Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection) 789.39 Abdominal or pelvic swelling, mass, or lump, other specified site 998.2 Accidental puncture or laceration during procedure

ICD-10 K92.2 K56.5 R19.09 D78.12 K91.72 K91.71

567.21 Peritonitis (acute) generalized 789.33 Abdominal or pelvic swelling, mass, or lump, right lower quadrant 789.37 Abdominal or pelvic swelling, mass, or lump, generalized 789.34 Abdominal or pelvic swelling, mass, or lump, left lower quadrant 789.69 Abdominal tenderness, other specified site 789.63 Abdominal tenderness, right lower quadrant 789.61 Abdominal tenderness, right upper quadrant 789.64 Abdominal tenderness, left lower quadrant 789.60 Abdominal tenderness, unspecified site 789.9

Other symptoms involving abdomen and pelvis

789.67 Abdominal tenderness, generalized 789.31 Abdominal or pelvic swelling, mass, or lump, right upper quadrant 789.66 Abdominal tenderness, epigastric 789.36 Abdominal or pelvic swelling, mass, or lump, epigastric 789.32 Abdominal or pelvic swelling, mass, or lump, left upper quadrant 789.35 Abdominal or pelvic swelling, mass or lump, periumbilic 789.40 Abdominal rigidity, unspecified site 789.47 Abdominal rigidity, generalized 789.41 Abdominal rigidity, right upper quadrant 427.31 Atrial fibrillation 518.81 Acute respiratory failure

K65.0 R19.03 R19.07 R19.04 R10.819 R10.829 R10.813 R10.823 R10.811 R10.821 R10.814 R10.824 R10.819 R10.829 R19.8

789.07 Abdominal pain, generalized 486 Pneumonia, organism unspecified 786.09 Other dyspnea and respiratory abnormalities

Gastrointestinal hemorrhage, unspecified Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection) Other intra-abdominal and pelvic swelling, mass and lump Accidental puncture and laceration of the spleen during other procedure Accidental puncture and laceration of a digestive system organ or structure during other procedure Accidental puncture and laceration of a digestive system organ or structure during GI procedure Generalized (acute) peritonitis Right lower quadrant abdominal swelling, mass and lump Generalized intra-abdominal and pelvic swelling, mass and lump Left lower quadrant abdominal swelling, mass and lump

R10.817 R10.827 R19.01

Abdominal tenderness, unspecified site Rebound abdominal tenderness, unspecified site Right lower quadrant abdominal tenderness Right lower quadrant rebound abdominal tenderness Right upper quadrant abdominal tenderness Right upper quadrant rebound abdominal tenderness Left lower quadrant abdominal tenderness Left lower quadrant rebound abdominal tenderness Abdominal tenderness, unspecified site Rebound abdominal tenderness, unspecified site Other specified symptoms and signs involving the digestive system and abdomen Generalized abdominal tenderness Generalized rebound abdominal tenderness Right upper quadrant abdominal swelling, mass and lump

R10.816 R10.826 R19.06 R19.02

Abdominal tenderness, epigastric Epigastric rebound abdominal tenderness Epigastric swelling, mass or lump Left upper quadrant abdominal swelling, mass and lump

R19.05 R19.30 R19.37 R19.31 I48.91 J96.00

Periumbilic swelling, mass or lump Abdominal rigidity, unspecified site Generalized abdominal rigidity Right upper quadrant abdominal rigidity Unspecified atrial fibrillation Acute respiratory failure, unspecified whether with hypoxia or hypercapnia Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia Epigastric pain Upper abdominal pain, unspecified Pelvic and perineal pain Lower abdominal pain, unspecified Generalized abdominal pain Pneumonia, unspecified organism Dyspnea, unspecified Other forms of dyspnea Other abnormalities of breathing

J96.90 789.06 Abdominal pain, epigastric 789.09 Abdominal pain, other specified site

ICD-10 descriptor

R10.13 R10.10 R10.2 R10.30 R10.84 J18.9 R06.00 R06.09 R06.89

853.e5 Brill et al

Gastroenterology Vol. 146, No. 3

Continued ICD-9

ICD-9 descriptor

787.99 Other symptoms involving digestive system

569.89 780.2 789.03 276.51 789.04 789.01 998.59

427.89

415.19 038.9 428.23 410.71 560.2 453.41

428.33 507.0 998.12

518.51

569.69 038.49 038.42 410.41 569.60 562.11 560.9 558.9

ICD-10 R19.4 R19.8

ICD-10 descriptor

Change in bowel habit Other specified symptoms and signs involving the digestive system and abdomen Other specified disorder of intestines K63.89 Other specified diseases of intestine Syncope and collapse R55 Syncope and collapse Abdominal pain, right lower quadrant R10.31 Right lower quadrant pain Dehydration E86.0 Dehydration Abdominal pain, left lower quadrant R10.32 Left lower quadrant pain Abdominal pain, right upper quadrant R10.11 Right upper quadrant pain Other postoperative infection K68.11 Postprocedural retroperitoneal abscess T81.4XXA Infection following a procedure, initial encounter T81.4XXD Infection following a procedure, subsequent encounter T81.4XXS Infection following a procedure, sequela Other specified cardiac dysrhythmias I49.8 Other specified cardiac arrhythmias R00.1 Bradycardia, unspecified R00.0 Tachycardia, unspecified Other pulmonary embolism and infarction I26.99 Other pulmonary embolism without acute cor pulmonale Unspecified septicemia A41.9 Sepsis, unspecified organism Acute on chronic systolic heart failure I50.23 Acute on chronic systolic (congestive) heart failure Acute myocardial infarction, subendocardial infarction, initial I21.4 Non-ST elevation (NSTEMI) myocardial infarction episode of care Volvulus K56.2 Volvulus Acute venous embolism and thrombosis of deep vessels of I82.419 Acute embolism and thrombosis of unspecified femoral proximal lower extremity vein I82.429 Acute embolism and thrombosis of unspecified iliac vein I82.439 Acute embolism and thrombosis of unspecified popliteal vein I82.4Y9 Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity Acute on chronic diastolic heart failure I50.33 Acute on chronic diastolic (congestive) heart failure Pneumonitis due to inhalation of food or vomitus J69.0 Pneumonitis due to inhalation of food and vomit Hematoma complicating a procedure D78.22 Postprocedural hemorrhage and hematoma of the spleen following other procedure K91.61 Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure K91.62 Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating other procedure K91.840 Postprocedural hemorrhage and hematoma of a digestive system organ or structure following a digestive system procedure K91.841 Postprocedural hemorrhage and hematoma of a digestive system organ or structure following other procedure Acute respiratory failure following trauma and surgery J95.821 Acute postprocedural respiratory failure J96.00 Acute respiratory failure, unspecified whether with hypoxia or hypercapnia Other complication of colostomy or enterostomy K94.09 Other complications of colostomy K94.19 Other complications of enterostomy Other septicemia due to gram-negative organism A41.59 Other gram-negative sepsis Septicemia due to Escherichia coli (E. coli) A41.51 Sepsis due to Escherichia coli [E. coli] Acute myocardial infarction of other inferior wall, initial I21.19 ST elevation (STEMI) myocardial infarction involving other episode of care coronary artery of inferior wall Unspecified complication of colostomy or enterostomy K94.00 Colostomy complication, unspecified K94.10 Enterostomy complication, unspecified Diverticulitis of colon (without mention of hemorrhage) K57.32 Diverticulitis of large intestine without perforation or abscess without bleeding Unspecified intestinal obstruction K56.60 Unspecified intestinal obstruction Other and unspecified noninfectious gastroenteritis and K52.89 Other specified noninfective gastroenteritis and colitis colitis K52.9 Noninfective gastroenteritis and colitis, unspecified

March 2014

AGA SECTION 853.e6

Continued ICD-9

ICD-9 descriptor

780.79 Other malaise and fatigue

584.9 786.59 285.1 427.32 729.5 780.97 780.60

Acute kidney failure, unspecified Chest pain, other Acute posthemorrhagic anemia Atrial flutter Pain in soft tissues of limb Altered mental status Fever, unspecified

ICD-10 R53.1 R53.81 R53.82 R53.83 N17.9 R07.89 D62 I48.92 M79.609 R41.82 R50.2 R50.9

ICD-10 descriptor Weakness Other malaise Chronic fatigue Other fatigue Acute kidney failure, unspecified Other chest pain Acute posthemorrhagic anemia Unspecified atrial flutter Pain in unspecified limb Altered mental status, unspecified Drug induced fever Fever, unspecified

853.e7 Brill et al

Gastroenterology Vol. 146, No. 3

Inpatient Inclusions

ICD-9

ICD-9 descriptor

ICD-10

562.12

Diverticulosis of colon with hemorrhage

K57.31

569.85 578.9 569.83 998.11

Angiodysplasia of intestine with hemorrhage Hemorrhage of gastrointestinal tract, unspecified Perforation of intestine Hemorrhage complicating a procedure

K55.21 K92.2 K63.1 D78.02 D78.22 K91.61 K91.62 K91.840

K91.841 998.2

Accidental puncture or laceration during procedure

D78.12 K91.71 K91.72

560.81 789.30 567.21 789.05 789.02 569.42 789.39 038.9 518.81

Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection) Abdominal or pelvic swelling, mass or lump, unspecified site Peritonitis (acute) generalized Abdominal pain, periumbilic Abdominal pain, left upper quadrant Anal or rectal pain Abdominal or pelvic swelling, mass, or lump, other specified site Unspecified septicemia Acute respiratory failure

K56.5 R19.00 K65.0 R10.33 R10.12 K62.89 R19.09 A41.9 J96.00

ICD-10 descriptor Diverticulosis of large intestine without perforation or abscess with bleeding Angiodysplasia of colon with hemorrhage Gastrointestinal hemorrhage, unspecified Perforation of intestine (nontraumatic) Intraoperative hemorrhage and hematoma of the spleen complicating other procedure Postprocedural hemorrhage and hematoma of the spleen following other procedure Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating other procedure Postprocedural hemorrhage and hematoma of a digestive system organ or structure following a digestive system procedure Postprocedural hemorrhage and hematoma of a digestive system organ or structure following other procedure Accidental puncture and laceration of the spleen during other procedure Accidental puncture and laceration of a digestive system organ or structure during GI procedure Accidental puncture and laceration of a digestive system organ or structure during other procedure Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection) Intra-abdominal and pelvic swelling, mass and lump, unspecified site Generalized (acute) peritonitis Periumbilical pain Left upper quadrant pain Other specified diseases of anus and rectum Other intra-abdominal and pelvic swelling, mass and lump

486 518.51

Pneumonia, organism unspecified Acute respiratory failure following trauma and surgery

J18.9 J95.821 J96.00

427.31 276.51 428.23 507.0 998.59

Atrial fibrillation Dehydration Acute on chronic systolic heart failure Pneumonitis due to inhalation of food or vomitus Other postoperative infection

410.71

Acute myocardial infarction, subendocardial infarction, initial episode of care Obstructive chronic bronchitis, with (acute) exacerbation Blood in stool Acute on chronic diastolic heart failure

I48.91 E86.0 I50.23 J69.0 K68.11 T81.4XXA T81.4XXD T81.4XXS I21.4

Sepsis, unspecified organism Acute respiratory failure, unspecified whether with hypoxia or hypercapnia Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia Pneumonia, unspecified organism Acute postprocedural respiratory failure Acute respiratory failure, unspecified whether with hypoxia or hypercapnia Unspecified atrial fibrillation Dehydration Acute on chronic systolic (congestive) heart failure Pneumonitis due to inhalation of food and vomit Postprocedural retroperitoneal abscess Infection following a procedure, initial encounter Infection following a procedure, subsequent encounter Infection following a procedure, sequela Non-ST elevation (NSTEMI) myocardial infarction

J44.1

Chronic obstructive pulmonary disease with (acute) exacerbation

K92.1 I50.33

Melena Acute on chronic diastolic (congestive) heart failure

J96.90

491.21 578.1 428.33

March 2014

AGA SECTION 853.e8

Continued ICD-9 998.12

ICD-9 descriptor Hematoma complicating a procedure

ICD-10 D78.22 K91.61 K91.62 K91.840

K91.841 569.3 415.19 569.69

Hemorrhage of rectum and anus Other pulmonary embolism and infarction Other complication of colostomy or enterostomy

560.2 453.41

Volvulus Acute venous embolism and thrombosis of deep vessels of proximal lower extremity

038.49 789.00 569.89 427.89

Other septicemia due to gram-negative organism Abdominal pain, unspecified site Other specified disorder of intestines Other specified cardiac dysrhythmias

038.42 780.2 789.07 410.41 786.50 789.09

Septicemia due to Escherichia coli (E. coli) Syncope and collapse Abdominal pain, generalized Acute myocardial infarction of other inferior wall, initial episode of care Chest pain, unspecified Abdominal pain, other specified site

786.09

Other dyspnea and respiratory abnormalities

789.06 787.01 789.03 789.04 786.05 789.01 569.60

560.9 584.9 997.49

Abdominal pain, epigastric Nausea with vomiting Abdominal pain, right lower quadrant Abdominal pain, left lower quadrant Shortness of breath Abdominal pain, right upper quadrant Unspecified complication of colostomy or enterostomy Diverticulitis of colon (without mention of hemorrhage) Acute on chronic combined systolic and diastolic heart failure Unspecified intestinal obstruction Acute kidney failure, unspecified Other digestive system complications

421.0 518.84

Acute and subacute bacterial endocarditis Acute and chronic respiratory failure

562.11 428.43

K62.5 I26.99 K94.09 K94.19 K56.2 I82.419 I82.429 I82.439 I82.4Y9 A41.59 R10.9 K63.89 I49.8 R00.1 A41.51 R55 R10.84 I21.19 R07.9 R10.10 R10.2 R10.30 R06.00 R06.09 R06.89 R10.13 R11.2 R10.31 R10.32 R06.02 R10.11 K94.00 K94.10 K57.32 I50.43 K56.60 N17.9 K91.3 K91.81 K91.82 K91.89 I33.0 J96.20

ICD-10 descriptor Postprocedural hemorrhage and hematoma of the spleen following other procedure Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating a digestive system procedure Intraoperative hemorrhage and hematoma of a digestive system organ or structure complicating other procedure Postprocedural hemorrhage and hematoma of a digestive system organ or structure following a digestive system procedure Postprocedural hemorrhage and hematoma of a digestive system organ or structure following other procedure Hemorrhage of anus and rectum Other pulmonary embolism without acute cor pulmonale Other complications of colostomy Other complications of enterostomy Volvulus Acute embolism and thrombosis of unspecified femoral vein Acute embolism and thrombosis of unspecified iliac vein Acute embolism and thrombosis of unspecified popliteal vein Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity Other gram-negative sepsis Unspecified abdominal pain Other specified diseases of intestine Other specified cardiac arrhythmias Bradycardia, unspecified Sepsis due to Escherichia coli [E. coli] Syncope and collapse Generalized abdominal pain ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall Chest pain, unspecified Upper abdominal pain, unspecified Pelvic and perineal pain Lower abdominal pain, unspecified Dyspnea, unspecified Other forms of dyspnea Other abnormalities of breathing Epigastric pain Nausea with vomiting, unspecified Right lower quadrant pain Left lower quadrant pain Shortness of breath Right upper quadrant pain Colostomy complication, unspecified Enterostomy complication, unspecified Diverticulitis of large intestine without perforation or abscess without bleeding Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure Unspecified intestinal obstruction Acute kidney failure, unspecified Postprocedural intestinal obstruction Other intraoperative complications of digestive system Post procedural hepatic failure Other postprocedural complications and disorders of digestive system Acute and subacute infective endocarditis Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia

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Gastroenterology Vol. 146, No. 3

Continued ICD-9 997.1

ICD-9 descriptor Cardiac complications

ICD-10 I97.88 I97.89

562.13

Diverticulitis of colon with hemorrhage

K57.33

560.1

Paralytic ileus

569.62

Mechanical complication of colostomy and enterostomy Acute vascular insufficiency of intestine Acute posthemorrhagic anemia Chest pain, other Acute myocardial infarction, unspecified site, subsequent episode of care Sinoatrial node dysfunction Other and unspecified noninfectious gastroenteritis and colitis Unspecified vascular insufficiency of intestine Acute and chronic respiratory failure following trauma and surgery

K56.0 K56.7 K94.03 K94.13 K55.0 D62 R07.89 I21.3

557.0 285.1 786.59 410.92 427.81 558.9 557.9 518.53

569.1

Rectal prolapse

790.7 780.79

Bacteremia Other malaise and fatigue

799.02

Hypoxemia

R00.1 K52.89 K52.9 K55.9 J95.822 J96.20 K62.2 K62.3 R78.81 R53.1 R53.81 R53.82 R53.83 R09.02

ICD-10 descriptor Other intraoperative complications of the circulatory system, not elsewhere classified Other postprocedural complications and disorders of the circulatory system, not elsewhere classified Diverticulitis of large intestine without perforation or abscess with bleeding Paralytic ileus Ileus, unspecified Colostomy malfunction Enterostomy malfunction Acute vascular disorders of intestine Acute posthemorrhagic anemia Other chest pain ST elevation (STEMI) myocardial infarction of unspecified site Bradycardia, unspecified Other specified noninfective gastroenteritis and colitis Noninfective gastroenteritis and colitis, unspecified Vascular disorder of intestine, unspecified Acute and chronic postprocedural respiratory failure Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia Anal prolapse Rectal prolapse Bacteremia Weakness Other malaise Chronic fatigue Other fatigue Hypoxemia

NOTE. The work group reviewed the ICD-9 codes and cross-referenced them to the equivalent ICD-10 codes.