GI Unit Leadership: Shaping a High-Performing Endoscopy Unit (On-Demand) | February 2026-07_Littenberg

07_Littenberg_Reimbursement

Pdf Summary

The 2026 reimbursement landscape for gastrointestinal (GI) procedures reflects significant updates across Hospital Outpatient Departments (HOPD), Ambulatory Surgery Centers (ASC), and physician payments. Key points include:

1. <strong>Hospital Outpatient Payments (HOPD):</strong> Medicare uses Ambulatory Payment Classifications (APCs) to bundle payments for outpatient GI procedures. For 2026, HOPD payments show modest increases for most complex and level 2-3 upper and lower GI procedures (3-4%), while some level 1 upper GI endoscopy payments decrease slightly (-1%). Examples include ERCP with sphincterotomy (+4%) and colonoscopy with polypectomy (+4%). 

2. <strong>ASC Payments:</strong> ASC reimbursements for GI procedures also mostly rise by about 3-4%, with diagnostic and therapeutic colonoscopies, upper GI endoscopy, and gastrostomy placements reflecting these trends. Notable new additions to the ASC Covered Procedures List include device-intensive procedures like endoscopic defect closure, endoscopic submucosal dissection (ESD), peroral endoscopic myotomy (POEM), and endoscopic sleeve gastroplasty (ESG), with ASC payments reflecting their complexity.

3. <strong>New CPT Code for ESG:</strong> The new Category I CPT code 43889 replaces prior HCPCS coding for ESG starting in 2026, with payments of approximately $10,860 (HOPD), $5,121 (ASC), and $720 (physician). ESG coverage is expanding widely among Medicare, Medicaid programs, and numerous national and regional commercial payers, now covering over 90 million lives.

4. <strong>Physician Payments and Efficiency Adjustments:</strong> Physician work RVUs are reduced by 2.5% in 2026 due to CMS efficiency adjustments, reflecting expected productivity gains. This results in a 6-10% reduction in physician fees, including notable decreases in payments for common GI procedures such as EGD with biopsy (-7%), ERCP with stenting (-9%), and colonoscopy with lesion removal (-8%). The practice expense component is reduced by half for facility-based services.

5. <strong>Modifiers and Coding Guidance:</strong> Important ASC modifiers include -59 for secondary procedures, -73 and -74 for discontinued procedures before/after anesthesia, and -53 for physician-related cancellations. EndoFLIP (impedance planimetry) is now covered in ASCs. 

6. <strong>Resources:</strong> Updated payment charts and coding guides are available from GI societies, CMS, Boston Scientific, and Medtronic to assist providers in navigating the 2026 reimbursement environment.

In summary, 2026 brings modest increases in facility reimbursement for many GI procedures, the introduction of new covered and device-intensive endoscopic services in ASCs, expanding coverage for novel therapies like ESG, but also significant downward adjustments in physician payments due to CMS efficiency policies. Providers should carefully apply new codes and modifiers to optimize billing in this evolving reimbursement landscape.

Keywords

2026 GI procedure reimbursement

Hospital Outpatient Department payments

Ambulatory Surgery Center reimbursements

ESG CPT code 43889

Medicare and Medicaid coverage

Physician payment reductions 2026

CMS efficiency adjustments

Endoscopic submucosal dissection

Modifiers for ASC billing

EndoFLIP coverage