More than 190 health care organizations, hospitals, patient advocacy groups and screening sites cosigned a Dec. 28 letter questioning whether the Centers for Medicare & Medicaid Services (CMS) has provided adequate reimbursement for two low-dose CT (LDCT) lung cancer screening G codes.
The Lung Cancer Screening Coalition letter, spearheaded by the American College of Radiology (ACR), Lung Cancer Alliance (LCA), The Society of Thoracic Surgeons (STS), and the Medical Imaging and Technology Alliance (MITA), focuses on the negative impact of the Calendar Year 2017 Hospital Outpatient Prospective Payment System’s (HOPPS) final rule on patient access to both the LDCT shared decision-making visit (G0296) and actual LDCT screen (G0297). Both are essential parts of the clinically effective LDCT lung cancer screening protocol for older adults who are at high risk for developing the often lethal disease.
The 2017 HOPPS proposed rule attempted to reduce reimbursement rates for the shared decision-making session and LDCT lung cancer screen G codes by 64 percent and 44 percent, respectively, in comparison to 2016 payment rates. The shared decision-making code provides reimbursement to ordering physicians for discussing the potential benefits, drawbacks and importance of annual LDCT screenings with patients qualify for the exams.
With respected to the shared decision-making visit, CMS acknowledged after reviewing only 21 single claims in the HOPPS final rule that the geometric mean cost is $130.44. Because of the dearth of claims data, CMS ultimately elected to place the shared decision-making G code into Level 2 ambulatory payment classification (APC) 5822 with a corresponding payment rate of $70.23.
APCs are the federal government’s method of paying facilities for Medicare outpatient services. Each APC is composed of services that are similar in clinical intensity, resource utilization and cost. All services, which are grouped under a specific APC, result in an annually updated Medicare “prospective (or fixed) payment” for that particular APC. Since it’s a fixed level of reimbursement to the hospital, the facility accepts any potential financial profit or loss from each APC payment.
The combination of ACR’s direct advocacy and inquiries from members of Congress pressured CMS to alter the 2017 HOPPS proposed rule that would have lowered reimbursement to $25.08 for code G0296. In 2016, the shared decision-making visit was also placed in APC 5822 but with a corresponding payment rate of $69.65.
The payment for the shared decision-making visit outlined in the 2017 HOPPS final rule is considerably higher than rates outlined in the 2017 HOPPS proposed rule, though it is only slightly higher than 2016 reimbursement rate, In addition, the Agency acknowledged that CMS took into account clinical similarity when grouping the shared decision-making visit into APC 5822 and indicated it would review payment rates for G0296 in the 2018 rulemaking cycle.
CMS, however, finalized very different payment provisions as they relate to the actual LDCT scan and ultimately refused to retain the current 2016 APC payment rate of $112.49. Instead, the Agency placed G0297 into APC 5521 with a corresponding payment rate of $59.84. Unlike the shared decision-making code, CMS did not indicate it will reevaluate reimbursement rates for G0297 in 2018, and it rejected the ACR’s argument that the actual LDCT scan was no longer grouped into a clinically similar APC.
While the Lung Cancer Screening Coalition’s HOPPS final rule comment letter expresses appreciation for the slight reimbursement increase for the shared decision-making visit, it questions why CMS ultimately decided to place G0296 into an APC with a corresponding payment rate of $70.23 when the Agency’s internal claims analysis supports its inclusion in an APC with a reimbursement rate of $125.96. The coalition letter also applauds CMS for agreeing to review additional claims data in 2018, but it questions why the Agency initially relied on insufficient claims data in an attempt to severely cut reimbursement for the shared decision-making visit.
The coalition letter is far more critical of CMS for the reimbursement policies it finalized for the actual LDCT screen. The letter warns CMS that the dramatic reimbursement reductions will likely severely minimize patient access to annual LDCT scans primarily due to the disturbing reality that the shared decision-making visit will actually be reimbursed at a higher rate than the LDCT scan in 2017. The coalition also questions why, unlike the shared decision-making visit, the Agency refuses to indicate whether it will consult more robust claims data in 2018 in hopes of ultimately increasing the reimbursement rate for the LDCT scan.
CMS is under no statutory obligation to provide detailed feedback in response to comment letters submitted by outside stakeholders relating to final rules. Nevertheless, the coalition hopes the large number of diverse cosigners of this forceful letter will prompt CMS to increase reimbursement rates for the shared decision-making visit and LDCT screen through the 2018 HOPPS rulemaking cycle. The ACR appreciates the strong support for the Lung Cancer Screening Coalition’s HOPPS final rule comment letter and looks forward to working with these stakeholders in the future.