July 25, 2018

CMS Releases CY 2019 HOPPS Proposed Rule

On July 25th, 2018 the Centers for Medicare and Medicaid Services (CMS) released its proposed rule for changes to the calendar year (CY) 2019 hospital outpatient prospective payment system (HOPPS). This rule provides for a 60-day comment period ending on September 25, 2018. The finalized changes will appear in the final rule in early November and are effective January 1, 2019.

CMS is proposing to increase the conversion factor by 1.25 percent bringing it up to $79.546 for CY 2019. The reduced conversion factor for hospitals failing to meet the Hospital Outpatient Quality Reporting (OQR) Program requirements is proposed to be $77.955.

In CY 2019, CMS was due to terminate the transition period for its policy on the use of CT and MR cost data and would estimate the imaging APC relative payment weight using cost data from all providers regardless of cost allocation statistic employed (i.e. direct, dollar or square foot method). The ACR has raised concerns regarding using claims from all providers to calculate CT and MR cost-to-charge ratios (CCRs) because many providers continue to use the “square feet” cost allocation method and that including claims from such providers would cause significant reductions in imaging APC payment rates. In a meeting with CMS earlier this year, ACR requested that the CT and MR cost centers be deleted and that hospitals be allowed to report these costs under the standard diagnostic imaging cost center. Instead, CMS is proposing to continue the transition period for CY 2019, providing flexibility for hospitals to improve their cost allocation methods. Beginning in CY 2020, CMS is due to determine the imaging APC relative payment weights for CY 2020 cost data from all providers, regardless of the cost allocation method employed.

In the CY 2019 OPPS Proposed Rule, CMS is proposing to continue placing G0297 (Low Dose CT for Lung Cancer Screening) in the lowest Imaging without Contrast APC (5521), with an increased payment for the service from $59.17 to $62.86. In addition, CMS has proposed to place G0296 (visit to determine lung LDCT eligibility) in APC 5822, with a minor payment increase for the service from $68.92 to $73.02. The ACR has raised concerns about the inadequate payments for CT lung screening based on flawed hospital data in the past few rules and the need for this screening benefit to be more readily available to the millions of Americans who would benefit from early detection of lung cancer.

CMS is proposing the creation of three new C-APCs for the CY 2019. These three new C-APCs are as follows: C-APC 5163 (Level 3 ENT Procedures), C-APC 5183 (Level 3 Vascular Procedures), and C-APC 5184 (Level 4 Vascular Procedures). CMS also is soliciting comments on expanding the C-APCs for endovascular revascularization from 4 levels to as many as 6. The higher levels may allow for more accurate payments for more complex cases that use more expensive devices.

CMS does not propose any new changes to the APC structure for imaging codes. The seven payment categories remain. However, CMS has move codes within these payment categories of which would cause changed pricing for 2019.


Moreover, CMS is proposing to continue making separate payment for the 10 planning and preparation services adjunctive to the delivery of Stereotactic Radio Surgery (SRS) treatments using Cobalt-60-based or LINAC-based technology when these services are furnished to beneficiaries within 30 days of SRS treatment.

CMS is proposing additional changes to the Appropriate Use Criteria program. The AUC program applies to the Medicare Physician Fee Schedule (MPFS), the Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center rules. More details on this proposal will be included in the ACR summary of the CY 2019 MPFS proposed rule.

The CMS is proposing to continue paying for drugs and therapeutic radiopharmaceuticals at ASP + 6 percent as set forth in the CY 2010 OPPS/ASC Final Rule. The proposed threshold payment for therapeutic radiopharmaceuticals is $125 where CMS will package those that are priced less or equal to $125 into the APC payments and pay separately for those that meet or exceed this threshold amount.

CMS proposes to continue to pay Off-campus sites that are more than 250 yards from the main campus and began providing services on or after November 2, 2015 at 40 percent of the HOPPS rate. A detailed discussion of this proposal appears in the physician fee schedule proposed rule. However, in this OPPS proposed rule CMS solicits comments on how to maintain access to new innovations while controlling for unnecessary increases in the volume of covered hospital OPD services. CMS also seeks comments on additional items and services paid under the OPPS that may represent unnecessary increases in OPD utilization and also examples of when it might be appropriate for higher payments to a hospital outpatient site versus other sites-of-service.

ACR staff is preparing a detailed analysis of the proposed rule and will provide additional information in the coming week.