Rule Changes Could Impact ACR Members


Proposed regulatory changes could have a serious negative impact on many ACR members next year if they are adopted over the ACR's opposition. If approved, the new rules would take effect on or about January 1, 2006, if federal officials do not consider recently submitted comments when they issue the final rule, likely sometime in November.

Officials with the Centers for Medicare and Medicaid Services (CMS) released the proposal for 2006 changes to the hospital outpatient prospective payment system (HOPPS) and ambulatory payment categories (APC). The proposal, published in the July 25 edition of the Federal Register, calls for the implementation of a Medicare Payment Advisory Commission recommendation to "reduce the technical component payment for multiple imaging services performed on contiguous body parts." The same proposal was included in CMS' recently released proposed Medicare Physician Fee Schedule (MPFS).

CMS Proposal

According to the proposal, Medicare will pay 100% of the technical component of the highest value procedure and only 50% for additional procedures in the same "family" when performed in the same session.

CMS officials have identified 11 "families" of related procedures that they propose subjecting to the proposed payment reductions. (See complete list of procedures in accompanying sidebar.) The average predicted impact on the designed group of procedures is -8.3%, with CT and CTA of the chest, thorax, abdomen, and pelvis expected to see the largest reduction at -18.9%. Together, the 11 families of procedures accounted for 2004 Medicare allowed charges of more than $2.2 billion.

The ACR's Concerns

The ACR firmly disagrees with this proposed payment modification and the assumptions of CMS officials in drafting the proposal.

On August 18, John A. Patti, MD, chair of the ACR Commission on Economics, testified before the APC Advisory Panel on the ACR's stance that CMS has used external, rather than internal, data and methodology to analyze their proposal. He emphasized that in using the Medicare Physician Fee Schedule (MPFS) methodology and data, CMS has ignored that the cost efficiencies of performing multiple imaging procedures in the same session already are captured and accounted for in hospitals' annual cost reports to CMS. Following the testimony, the APC Advisory Panel voted unanimously to recommend that CMS delay this proposal for 1 year and consult with the ACR and other stakeholders to determine an appropriate methodology to address these economies.

Moreover, in the "Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2006 Proposed Rule," published in the August 8 Federal Register, CMS proposed the same 50% reduction of payment for the technical component for CPT codes in the same 11 families included in the HOPPS proposal. However, the ACR's opposition to this proposal is based on a different methodology and will indicate evidence contained in the direct practice expense inputs to the Practice Expense Advisory Committee (PEAC) that supports economies of much less than 50% when multiple CT, MR, or ultrasound procedures are performed in the same session.

In its September 29 comment letter to CMS, the ACR expressed concern that the payment reductions that CMS proposed are based on inputs developed by the PEAC which are just now being implemented. As James P. Borgstede, MD, chair of the ACR's Board of Chancellors said in his March 17 testimony before the Health Subcommittee of the House Ways and Means Committee, implementing any multiple procedure reduction should be delayed until the resource-based practice expense inputs have been fully implemented and clearly defined. The ACR has submitted both socioeconomic monitoring system-like supplemental data and code specific direct practice expense inputs (clinical time, supplies, and equipment) for this process.

Questions/Comments

ACR members are encouraged to check the ACR Web site (www.acr.org) for the latest developments regarding the proposed Medicare Physician Fee Schedule. If you have questions regarding these issues, please contact Pamela Kassing, senior director, Economics and Health Policy Department, at (800) 227-5463, ext 4544, or at pkassing @acr.org.

The 11 families of imaging procedures in CMS' plan to reduce Medicare payments for certain imaging procedures includes:

  • Ultrasound (chest/abdomen/pelvis – nonobstetrical)
  • CT and CTA (chest/thorax/abdomen/pelvis)
  • CT and CTA (head/brain/orbit/maxillofacial/neck)
  • MRI and MRA (chest/abdomen/pelvis)
  • MRI and MRA (head/brain/neck)
  • MRI and MRA (spine)
  • CT (spine)
  • MRI and MRA (lower extremities)
  • CT and CTA (lower extremities)
  • MR and MRI (upper extremities and joints)
  • CT and CTA (upper extremities)