ACR Acts to Improve 2004 HOPPS
More than 70 percent of the members of the American College of Radiology are hospital-based physicians who are indirectly impacted by payment systems that affect hospital cost centers. For this reason, the ACR has been working closely with the Centers for Medicare and Medicaid Services to promote adequate Medicare reimbursement for radiology and radiation oncology in hospital outpatient settings.
The Hospital Outpatient Prospective Payment System and the corresponding Ambulatory Payment Classifications make up the prospective payment method used by CMS to reimburse hospitals for costs related to supplies, equipment and clinical staff time incurred through outpatient services. Hospital-based physicians receive their professional component reimbursement through the Medicare Physician Fee Schedule. By working closely with CMS on the HOPPS/APC system, the ACR strives to not only help ensure proper payment for radiology and radiation oncology procedures in outpatient settings, but also to promote the correct coding of radiology and radiation oncology services. The delivery of high-quality care to all Medicare beneficiaries could be jeopardized if hospitals do not receive adequate reimbursement to cover the costs of that care.
The ACR analyzed the economic impact of all the proposed reimbursement policies for 2004 in CMS' HOPPS and identified cases where payment was inadequate and needed adjustment to ensure quality patient care. As a result, significant improvements in Medicare reimbursement have been made, including:
Separate Payment for Brachytherapy Seeds
CMS has agreed to the ACR request for separate payment for brachytherapy seeds for more appropriate reimbursement. The brachytherapy source will now be paid on a cost basis, allowing the costs of all sources to be reimbursed more appropriately than they were in 2003 (when the costs were bundled in the procedure and the separate costs for the sources were not fully captured). Although encouraged by this development, the College must continue to work with CMS to ensure that supplies, such as needles and catheters, are also covered in the APC reimbursement.
Adequate Payment for IMRT
The ACR, in conjunction with other organizations, was able to prevent a drastic cut of 62.5 percent in IMRT treatment planning reimbursement, which would have represented a cut of approximately $328 per procedure.
Changes for PET Codes
The ACR supported CMS' decision to: 1) create a new code for positron emission tomography for thyroid cancer evaluation, and 2) move all other PET codes out of their current new technology APCs to regular APCs using existing hospital costs data. The ACR believes existing hospital costs data has now proven to be sufficient in representing the true costs involved in these procedures. The payment rate for all PET procedures in 2004 will increase from $1,375 to $1,450.
Reclassification of Nuclear Medicine APCs
The College was also involved in improving CMS' classification of 20 new nuclear medicine APCs into 20 new organ-based APCs (i.e., lung, bone, etc). Almost all of the ACR's recommendations on the further structuring of these APC codes were accepted and will be applied for the 2004 reimbursement payments. We believe this reclassification represents a more homogeneous categorization for the nuclear medicine APCs. It also is consistent with congressional standards and will allow continued access to high- quality care for Medicare recipients.
Separate Payment for More Radiopharmaceuticals
Previously, CMS required a $150 threshold on the cost of radiopharmaceuticals for separate payment. In a positive move forward, CMS now requires a $50 threshold, a change that will establish accurate payment and allow for the tracking of the costs of those radiopharmaceuticals that cost less than $150. With this criterion, hospitals will now be able to receive separate reimbursement for those radiopharmaceuticals that cost more than $50; in 2003 these radiopharmaceuticals were bundled into procedures and costs were not appropriately accounted for.
Diagnostic Mammography Removed from HOPPS in 2005
As a result of provisions contained in the recently enacted prescription drug/Medicare reform bill, diagnostic procedures performed in a hospital outpatient setting will be reimbursed at the Medicare Fee Schedule rate starting in 2005. Currently set at $35.86, reimbursement is expected to increase to near the 2004 MFS levels for unilateral ($41.82) and bilateral ($51.53) mammography. Congress and the ACR believe this step will help ease the mammography access problem caused by the hundreds of facilities that have closed over the last several years.
All these improvements lead to a better reimbursement system for radiology and radiation oncology. The ACR will continue to work with CMS on proper reimbursement for computer tomographic angiography codes and IMRT delivery, universal coverage for low osmolar contrast material and other issues that may compromise access and quality of care for Medicare beneficiaries. As part of our effort to secure adequate reimbursement through correct coding practices, we also will continue to educate hospital outpatient departments on how to correctly code for procedures.
The College appreciates the involvement of its members and remains committed to the important concerns of radiology and radiation oncology.