September 09, 2016

ACR Voices Concerns About HOPPS Proposed Rule

In Sept. 6 comments to the Centers for Medicare & Medicaid Services (CMS), the American College of Radiology (ACR) warned against provisions in the 2017 Proposed Rule on the Hospital Outpatient Prospective Payment System (HOPPS). CMS is proposing several changes that would result in major reimbursement cuts for radiological procedures including CT lung and MR codes. The ACR commented extensively on this rule with regard to lack of concern by CMS on the impacts of radiology studies in the hospital outpatient setting and the proposal’s lack of transparency as to the centers’ intent and rationale.

The ACR is concerned with CMS’ proposed Ambulatory Payment Classification (APC) restructure and the absence of code-level clinical similarity in APC assignments. The restructure appears to place studies in categories sorted solely by their average cost with little attention paid to the mandated requirement that they be clinically similar nor to look at the potential impacts they cause on individual payments. For example, CMS’ APC placement of the CT lung codes, G0296 (clinical decision-making) and G0297 (CT lung screening), would result in reimbursement cuts of 65 percent and 45 percent, respectively. The placement of MR without contrast codes not only results in reimbursement cuts for hospitals but would impose a 19 percent cut in the office setting due to Deficit Reduction Act (DRA) requirements.

In a recent meeting with CMS, the ACR asked if this was the centers’ intent, and it appears that these placements were done with lack of regard to impacts. Therefore, ACR commented extensively on this section to not only point out significant problems but also to make proposals that would stabilize radiology hospital outpatient payments for these and many other studies.

Not unlike the lack of transparency seen in the APC restructure, CMS proposed a new claim-level packaging policy but failed to include implementation details so that the ACR’s consultants can check for impacts to radiology. Analysis of similar proposed policies in the past have saved hundreds of millions of dollars in interventional radiology payments in HOPPS. The ACR asked CMS to delay moving forward with this proposal until it provides such information.

In keeping with its expansion of the Comprehensive Ambulatory Payment Classifications (C-APCs) in previous years, CMS has proposed implementing five additional C-APCs, bringing the total to 40. The ACR asked CMS to reconsider this aggressive expansion of C-APCs and to further review and explain the lack of clinical similarity and the basis for capturing of costs to set the rates for these episode payments at a level that are somewhat equal to what hospitals would have received if CMS were to pay for their components individually. The ACR has pointed out to CMS in several meetings that costs for these episodes, including endovascular revascularization and now stereotactic radiosurgery, are not fully captured, which means hospitals are being underpaid.

Additionally, CMS proposes to make site-neutral payments to new off-campus sites that provide items and services to outpatients based on the Medicare Physician Fee Schedule (MPFS) technical component rate and would deny their eligibility for payment under HOPPS. This proposal stems from Section 603 of the Bipartisan Budget Act of 2015, which requires certain items and services furnished by certain off-campus sites to not be considered covered outpatient department services for purposes of reimbursement through the Outpatient Prospective Payment System (OPPS).

The ACR suggested that CMS has overstepped the intent of Section 603 and requested that it not be so expansive in its proposed policy, which could have detrimental impacts on the affected hospital-owned sites. The ACR recommended exempting imaging centers from this overly onerous proposal in deference to the already long history of reimbursement cuts that have been repeatedly applied to the technical component of imaging codes applicable to the physician fee schedule for these services since 2006.

A Technical Appendix developed by The Moran Company, accompanies the ACR letter and serves to request additional information from CMS regarding the methodology underlying much of the proposed rule.

For more information, contact Pamela Kassing, ACR senior economic advisor, at 703-648-8900 (Ext. 4544) or Dominick Parris, ACR analyst, at 703-648-8900 (Ext. 5652).