Ambulatory Payment Classification Assignment Also Included In The Federal Register
REDMOND, Washington – EndoGastric Solutions® (EGS), a leader in incisionless procedural therapy for gastroesophageal reflux disease (GERD), today announced the Federal Register has posted coding and payment information specific to the new Current Procedural Terminology (CPT)® code covering the Transoral Incisionless Fundoplication (TIF®) procedure.
Physician payment for CPT 43210 EGD esophagogastric fundoplasty has been given 12.43 relative value units (RVU); using the established Centers for Medicare and Medicaid (CMS) CY2016 conversion factor, 35.8279, this translates to a national unadjusted payment amount of $445.34.
For hospital outpatient payment, CPT 43210 has been grouped to APC 5331 Complex GI Procedures. This has a national unadjusted payment amount of $3,613.57. APCs are the federal government’s facility payments for outpatient Medicare services.
Physicians and hospitals will be able to reference CPT Code 43210 EGD esophagogastric fundoplasty and APC 5331 Complex GI Procedures for TIF procedures on or after January 1, 2016.
“Now that RVU and APC assignments for the new Category 1 CPT code 43210 have been finalized for use, healthcare providers should have a more effective pathway to appropriately receive reimbursement,” said Philip Macdonald, Vice President, Healthcare Economics, Policy and Reimbursement. “A larger percentage of GERD sufferers will have access to the TIF procedure as an option to resolve their chronic symptoms and help improve their quality of life.”
The relative value unit (RVU) assignment is based on the amount of the physician’s work, practice expense and malpractice expense associated with the procedure. The AMA formed the AMA/Specialty Society Relative Value Scale Update Committee (RUC) to act as an expert panel in developing relative value recommendations to the Centers for Medicare & Medicaid Services (CMS). The purpose of the RUC process is to provide recommendations to CMS for use in annual updates to the new Medicare RVS. Manufacturers have no impact or input into the assignment of RVUs.
“EGS invested in obtaining Level 1 evidence from randomized controlled trials to prove that the TIF procedure is an effective option to treat chronic acid reflux,” said Skip Baldino, President and CEO of EGS. “The CPT application was supported by four key surgical and gastroenterology societies—American Gastroenterological Association, American College of Gastroenterology, American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeon—who recognized the body of clinical evidence supported a dedicated CPT code.”
All outpatient services grouped under a specific APC are annually updated by the Centers for Medicare & Medicaid Services (CMS). Each APC is composed of services that are similar in clinical intensity, resource utilization and cost. Many service codes are derived directly from the American Medical Association’s CPT®.
“The APC classification assignment is also a significant step in the reimbursement process for the TIF procedure. We look forward to the increased economic value of the procedure for healthcare systems to provide chronic GERD patients this treatment option,” concluded Baldino.
About Current Procedural Terminology (CPT®)
CPT codes are a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of CPT is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians and other healthcare providers, patients, and third parties. CPT® is registered trademark of the American Medical Association.