- July 31, 2025
- Posted by: Josh Knoll
- Category: Gastroenterology
CMS has proposed significant changes to its 2026 payment rules that will affect how gastroenterology services are billed and paid. Some services will get lower payments, while others may receive more. These changes can impact your income, the billing process, and how your practice handles payments. It is crucial to get an overview of proposed changes from CMS, how this affects you, and how a professional gastroenterology billing service provider enables you to stay compliant and protect your revenue.
Overview of the Proposed CMS Changes
The new CMS proposal includes two big changes. First, it plans a 2.5% cut to work RVUs for non-time-based services. Second, it introduces a new way to calculate practice expenses, which will lower payments for procedures done in hospitals and surgery centers. These changes will affect how much you get paid for common services like colonoscopies, EGDs, and E/M visits.
Now, you should know about the potential payment cuts for facility-based gastroenterology services.
Payment Cuts for Facility-Based Services
If you perform endoscopic procedures in hospital outpatient departments (HOPDs) or ambulatory surgical centers (ASCs), you may see lower payments in 2026. The proposed rule includes an average 8% cut in endoscopy reimbursements compared to 2025. A colonoscopy with biopsy (CPT 45385) will pay $14.65 less, and a colonoscopy with snare polypectomy will pay $18.00 less per case. You often perform such gastroenterology procedures to remove larger or more complex polyps. It always takes more skill, time, and equipment. The cut in payment does not reflect the effort or cost involved, making it harder to cover overhead and maintain high-quality care. The Evaluation and Management (E/M) services provided by you in these settings might also receive 9% less and such cuts can heavily affect your revenue if most of your procedures are done in hospitals or ASCs.
On the other hand, if you perform endoscopy in an office-based setting, you may benefit from these changes. The proposed rule offers:
Payment Increase for Office-Based Procedures
The good thing is that office-centric gastroenterology practices may see an increase of 16% in endoscopy payments compared to the current year. You can also expect to receive $194.01 more for CPT 43249 for an EGD with dilation, which is performed to widen the narrowed areas in the upper digestive tract of your patients. This particular process requires you to use a special tool, trained staff, and careful monitoring; hence, the payment surge would help you over those additional efforts and costs.
E/M services in the office will also get an 8% boost. These changes clearly support shifting care to office settings. But not all practices have the space, staff, or equipment to safely perform advanced procedures outside hospitals or surgery centers.
The 2026 changes are just the beginning. Starting in 2027, more payment cuts are expected. The 2.5% efficiency adjustment will lower physician work payments every three years. Temporary payment boosts from past laws will also end, causing further reductions. The concerning thing is that these cuts will affect not just procedure billing but your total income and the long-term stability of your practice.
These proposed changes can create immediate and long-term challenges.
Related Reading: Gastroenterology Billing: Navigating the Surge in Preventive Screenings
Know how these changes can impact your gastroenterology billing services
Lower payments will make it harder to cover your daily costs. Moving care to an office setting may also mean spending more on equipment and staff. Billing will get more complicated, especially if you work in both office and hospital settings. Accurate coding and proper documentation will be more important to avoid denials. Practices that depend on hospital procedures may face cash flow problems. With so much changing, handling everything with only in-house staff can lead to mistakes, delays, and lost income.
Fortunately, a professional gastroenterology billing service provider can help you in the best possible manner as they understand the challenges these new rules bring.
Why You Need a Professional Gastroenterology Billing Service Provider
A professional gastroenterology billing service helps you in many ways. It keeps track of CMS updates and fee schedule changes, so your claims always follow the latest rules and avoid payment issues. With new RVU and practice expense rules, billing must be accurate. Billing experts use the correct CPT codes, modifiers, and values. If you do endoscopies in an office setting, they help you make the most of the higher payments by billing properly and documenting services well. They also review your current billing setup and suggest if shifting more work to the office can help your revenue. Claim denials and delays are reduced because they check and follow up on each claim quickly. You also get clear reports that show how changes are affecting your income. This helps you make smart decisions about staff, spending, and future plans. Since more cuts may come in 2027, a billing service can help you build a plan that protects your practice in the long run.
Related Reading: How to Manage Your Gastroenterology Billing
Be 2026-proof with a gastroenterology medical billing partner like SunKnowledge
The CMS 2026 proposal is a clear warning for gastroenterology practices. With lower payments for hospital-based services and better rates for office-based care, billing is now more complicated and risky. Choosing the right billing partner is key to staying on track. SunKnowledge Inc. is the perfect gastroenterology billing service provider to support your needs. We, at SunKnowledge, handle your complete billing process at just $7 per hour, giving you an instant boost in revenue while cutting your operational costs by up to 80%.
In today’s changing healthcare world, having expert billing support is not a choice—it is a must for your survival and future growth.