ACR Summary of Medicare Proposed HOPPS Changes for 2008
The Centers for Medicare and Medicaid Services (CMS) posted the review copy of its notice of proposed rule-making for the Hospital Outpatient Prospective Payment System late Monday, July 16, 2007. Following are the highlights of the significant changes that Medicare is proposing to make, which will affect radiology and radiation oncology in the hospital outpatient setting for 2008.
Medicare to Package Many Radiology Services and Drugs
CMS is proposing to package many radiology and radiation oncology services and drugs into procedural codes, thereby paying one consolidated payment for a service that commonly involves several coding components. In general, CMS believes that it is appropriate to package payment for the primary diagnostic or therapeutic modalities in which they are used. CMS is proposing to not pay separately for CPT or HCPCS codes which they describe as dependent items and services in the following categories and will instruct hospitals to report costs for them in the APC where the independent services are paid.
1) Guidance services — This would include all MR, CT, ultrasound, and stereotactic guidance bundled into the needle placement, biopsy, or various other procedural codes where guidance is usually associated.
2) Image processing services — 3-D post processing (CPT codes 76376 and 76377) will not be paid separately, but will be considered packaged into whichever services affiliated with their use.
3) Intraoperative services — Codes that are reported for supportive dependent diagnostic testing or other minor procedures performed during independent procedures (i.e., intraoperative ultrasound).
4) Imaging supervision and interpretation services — HCPCS codes (e.g., 72240, 75671, 93555) will all be packaged into their primary procedural codes in addition to contrast.
5) Stereoscopic x-ray (CPT code 77421) is to be bundled in with IMRT delivery (77418).
6) CMS currently packages payment for diagnostic radiopharmaceuticals and contrast agents with per day costs of $55 or less. However, CMS’ proposal for CY 2008 also includes packaging payment for all diagnostic radiopharmaceuticals and contrast agents, regardless of their per day cost. CMS views diagnostic radiopharmaceuticals and contrast agents as ancillary and supportive of the diagnostic tests.
7) CMS is also proposing to create a composite APC 8001, titled “LDR Prostate Brachytherapy Composite,” that would provide one bundled payment for low dose rate LDR prostate brachytherapy, when the hospital bills both CPT codes 55875 and 77778 as component services provided during the same hospital encounter.
Proposed Payment for Therapeutic Radiopharmaceuticals
For CY 2008, CMS is proposing to continue separate payment for therapeutic radiopharmaceuticals that have a mean per day cost of more than $60. The payment rates will be based on their mean unit cost as reported in the 2006 hospital claims data. CMS believes that the hospital data reflects both radiopharmaceutical charge and associated overhead charges. CMS considers several other methods that have been recommended to them throughout the year, such as: tighter trimming of the data, acceptance of external data collection of separate data from nuclear pharmacies, and its current method of using hospital charges reduced to cost using the hospitals’ overall cost-to-charge ratio.
However, CMS concluded that the method they propose for 2008 is the most accurate representation of a hospital’s true cost of therapeutic radiopharmaceuticals and handling costs. This issue is important because there are several therapeutic agents, such as monoclonial antibodies (i.e., Zevalin), that are being severely low-priced under APCs where hospitals are incurring losses and, in some cases, no longer offering this therapy. Not only is the cost of the drug not being covered, but also the costs of handling and transportation are not covered.
Positron Emission Tomography (PET)/Computed Tomography (CT) Scans
CMS is proposing to reassign the CPT codes for PET/CT scans to the clinical PAC where nonmyocardial PET scans are also assigned, specifically APC 0308, with a proposed median of $1, 093.52. This new payment rate includes the packaged payment for FDG.
Cardiac Computed Tomography and Computed Tomographic Angiography (APCs 0282, 0376, 0377, and 0398)
CMS is proposing to assign the cardiac CT and coronary CTA procedures to two new clinical APCs, specifically APC 0383 (Cardiac Computed Tomographic Imaging) and APC 0282 (Miscellaneous Computerized Axial Tomography). CMS is proposing to reassign the two other CCT CPT codes, specifically CPT codes 0144T and 0151T, to APC 0282. The proposed payment rate for APC 0383 is $313.81, and the payment rate for APC 0282 is $105.48.
Ultrasound Ablation of Uterine Fibroids with Magnetic Resonance Guidance (MRgFUS) (APCs 0195 and 0202)
CMS is proposing to accept the APC Panel’s recommendation to reassign CPT codes 0071T and 0072T codes to APC 0067, with a proposed APC median cost of $3,869.96.
Myocardial Positron Emission Tomography (PET) Scans (APC 0307)
CMS is proposing to continue to assign both the single and multiple myocardial PET scan procedure codes to APC 0307, with a proposed APC median cost of $2,677.71. This is significantly higher than its CY 2007 cost, partially because of CMS’ packaging approach that would package payment for diagnostic radiopharmaceuticals into the payment for their related diagnostic nuclear medicine studies.
Stereotactic Radiosurgery (SRS) Treatment Delivery Services (APCs 0065, 0066, and 0067)
CMS is proposing to continue with the CY 2007 HCPCS coding for LINAC-based SRS treatment delivery services under the OPPS; i.e., they will continue to use the G-codes for reporting LINAC-based SRS treatment delivery services; assign HCPCS codes G0173 and G0339 to APC 0067, HCPCS code G0251 to APC 0065, and HCPCS code G0340 to APC 0066.
Conversion Factor
The conversion factor for 2008 hospital outpatient payments will go up by 3.3%, from $61.47 to $64.77.
The ACR is very concerned about many of these major changes and will be commenting extensively on this proposed rule. Any ACR member who has questions or comments may contact Sneha Soni in the Economics and Health Policy Department at (800) 227-5453, ext. 4576 or by e-mail at ssoni@acr.org.
Click here to review the CMS Fact Sheet for the proposed HOPPS rule on the CMS Web site.