Gastroenterology Billing Under 2027 Medicare Payment Rules

Medicare reimbursement changes can significantly affect the financial stability of gastroenterology practices. The Centers for Medicare & Medicaid Services has finalized the 2027 Medicare Physician Fee Schedule, Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center payment rules. Beginning January 1, 2027, these changes will impact physician reimbursement, facility payments, coding and revenue cycle.

According to Becker’s ASC Review, physician payments for GI endoscopy services performed in ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs) will decline by an average of 2%. Although CMS has introduced some favorable payment adjustments, gastroenterology practices must prepare for lower reimbursement and increasing operational expenses. Knowing how these changes will impact your practice will help your GI billing team reduce revenue leakage. As it has become a complex affair for the in-house staff, this is where the need for a reputed gastroenterology billing company comes.

Understanding the 2027 Medicare Payment Reductions

The Medicare payment changes in 2027 will introduce financial challenges for gastroenterologists by reducing physician conversion factors. This is important for a practice that sees a high volume of Medicare patients.

CMS has finalized the conversion factors for 2027 based on qualifying Advanced APM participant status:

• For non-qualifying APM participants, the conversion factor decreases by 2.31%, from $33.40 in 2026 to $32.63 in 2027.
• The conversion factor for qualifying APM participants decreases by 1.83%, from $33.57 to $32.95.

The reduction is partially due to the temporary 2.5% Medicare physician payment increase introduced in 2026. The conversion factor is applied to geographically adjusted relative value units to calculate Medicare Physician Fee Schedule payments. CMS uses this figure, along with relative value units and geographic practice cost indices to calculate the physician payments. A lower conversion factor generally reduces Physician Fee Schedule reimbursement for affected services. This means your GI practice could lose a lot of money due to the high volumes of services.

Related Reading: How a Gastroenterology Billing Company manages complex Colonoscopy Claim Denials

Why Higher ASC Payment Updates May Not Benefit Gastroenterology Billing Process

CMS has finalized a 2.3% increase in payments for ASCs meeting quality-reporting requirements in 2027. However, this doesn’t mean your practice will receive increased payments for all procedures. It’s important to understand what changes have been made:

Procedure-Specific Reimbursement Remains a Concern

Although the overall ASC payment update is 2.3%, aggregate Medicare payments for many GI procedures performed in ASCs are expected to decline by approximately 1%. This is because of the way payments are calculated for facilities within Medicare. Facility payments will depend on the procedure classification, payment weights and other adjustments. Therefore, an overall payment increase does not necessarily translate into improved reimbursement for individual GI services. This is where the requirement for an expert gastroenterology billing company comes as the clinical staff struggle with the procedures.

Impact on GI Revenue Cycle Management

It is important for your billing teams to compare expected reimbursement against the applicable Medicare fee schedule. In addition to that, you can easily identify procedures with significant payment changes. This includes looking at contract changes and underpayments. If you can spot any discrepancies, you will be able to investigate why incorrect payments are being made to reduce denials.

New Endoscopic Submucosal Dissection Codes Bring GI Billing Opportunities

The 2027 CPT update introduce an updated version of Endoscopic Submucosal Dissection (ESD) procedures. This is an advanced procedure used to remove abnormal tissue from the gastrointestinal tract. If your claims are coded correctly, you will have new opportunities for GI practices.

The AMA has introduced two new CPT codes:

• CPT 43498: Endoscopic submucosal dissection (ESD) of upper gastrointestinal tract, including mucosal closure, when performed.
• CPT 45991: Endoscopic submucosal dissection (ESD) of lower gastrointestinal tract, including mucosal closure, when performed.

CMS has finalized work RVUs of 15.00 to CPT 43498 and 16.38 Work RVUs to CPT 45991. Both codes have also been allocated to APC 5331 for complex GI procedures under the 2027 OPPS final rules. According to Becker’s ASC, hospitals will be paid around $7,083 for these procedures.

Changes to Colonoscopy Quality Measures and MIPS

Changes to Medicare quality reporting will also impact your GI practice. For instance, two GI-related quality measures have been removed from the Merit-based Incentive Payment System in 2027. However, CMS has also removed the Normal Colonoscopy Follow-up Interval measure from ASC and Hospital Outpatient Quality Reporting Programs. Additionally, GI Practices should not assume all colonoscopy related reporting has been removed.

Same-Day E/M Billing Changes under the 2027 Medicare Rules

CMS has finalized a payment reduction for separately identifiable E/M services performed on the same day as zero-day global procedures.

Understand the 20% Payment Reduction in Gastroenterology Billing

CMS had proposed to reduce payments for some additional same day services to 50%. However, the final decision has adopted a less restrictive approach. The highest valued service will be paid at 100% of its applicable payment and the lowest valued service at 80%. The final decision has also been made for qualifying zero day global procedures.

What GI Billing Teams Should Check

Gastroenterology practices should check if their same day E/M claims meet Medicare criteria. Your billing team should ensure identifiable E/M services are properly documented. While the impact may not be too great for gastroenterologists as they rarely charge for E/M visits alongside endoscopy, clinics should review affected claims to avoid incorrect payments.

Related Reading: Reduce Documentation Errors with Gastroenterology Billing Services

How GI Practices Can Minimize Revenue Losses in 2027

It’s important to have a strong revenue cycle strategy in place to reduce claim denials. Ensuring you are coding accurately, monitoring payments and managing denials will help reduce any unnecessary revenue loss. Some important steps include:

• Ensure your coding system is up to date with the 2027 CPT changes and new Medicare billing rules.
• Compare expected reimbursement with applicable Medicare payment rates.
• Verify that documentation supports the services reported and meets applicable coding requirements.
• Manage any denials by identifying any patterns, investigating the root cause and taking action.
• Track your performance at a procedure level, looking at denial rates, AR and collections.

But as the clinical staff stay busy with patient care, this is why they don’t get time to tackle administrative hassles. This is where you can outsource to a specialized gastroenterology billing company whose experts stay updated with the latest coding procedures. Here, you may consider outsourcing to SunKnowledge in that matter.

How SunKnowledge Supports Gastroenterology Billing

Managing changing Medicare rules requires specialized billing knowledge which the billing team lacks. We help healthcare providers manage their billing operations through dedicated revenue cycle management support. Our experts help your clinic with the following:

• GI Medical Billing & Coding: Ensuring procedures are accurately coded.
• Insurance Verification: Ensuring patients are covered.
• AR Management: Monitoring any outstanding claims.
• Denial Management: Identifying the reason for claim denials, correcting claims and managing appropriate resubmissions and appeals.
• Payment Posting: Accurately recording payments.
• Revenue Cycle Management: Identifying any discrepancies with payments and any regular billing issues.

Having a specialist by your side can improve your claim accuracy, strengthen your reimbursement process and manage any administrative workload. By working with an experienced GI billing provider like SunKnowledge, you can spend more time looking after your patients while ensuring your revenue cycle is well managed. Are you looking for streamlined GI billing assistance? Request a demo to find out.

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