2016 Medicare Update. NMD Healthcare Consulting

52 

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Full text

(1)
(2)

Presenter

Rudy Karin

Director, Reimbursement Strategy

NMD Healthcare Consulting

(3)

Agenda

NM & PET Code Changes for CY 2016

– CPT & HCPCS Level II codes

Hospital Outpatient Prospective Payment System (HOPPS)

– Background

– Policy Changes

– Payment Rates

Physician Fee Schedule (MPFS)

– Background

– Repeal of SGR & impact on CF

– Policy Changes

(4)

NM & PET CODE CHANGES

CY 2016

(5)

New & Revised CPT Codes CY 2016

CPT Code

Long Descriptor

78264

Gastric Emptying Imaging Study (eg, solid, liquid or both);

78265

Gastric Emptying Imaging Study (eg, solid, liquid or both);

with small bowel transit

78266

Gastric Emptying Imaging Study (eg, solid, liquid or both);

with small bowel and colon transit, multiple days

(6)

New HCPCS Level II Codes CY 2016

6

HCPCS

Level II

Code

APC

Description

SI

1Q 2016 Rate

FINAL

(Proposed)

C9458

9458

Florbetaben F-18, diagnostic, per study

dose, up to 8.1 millicuries

(Trade Name: Neuraceq; Mfr’d by Piramal;

NDC# 54828-0001-30 (30 ml vial))

G

$2,968.00

C9459

9459

Flutemetamol F-18, diagnostic, per study

dose, up to 5 millicuries

(Trade Name: Vizamyl; Mfr’d by G.E.;

17156-0067-10 (10 ml vial) or 17156-0067-30 (30 ml

vial))

G

$3,135.00

Note: HCPCS Level II “C” codes can only be used in the hospital outpatient department provider setting.

Use A9599 – Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (PET imaging, per

study dose for studies performed in the free-standing clinic/Independent Diagnostic Testing Facility (IDTF)

(7)

HOSPITAL OUTPATIENT

PROSPECTIVE PAYMENT

SYSTEM (HOPPS) – 2016

(8)

Hospital Outpatient Prospective Payment

System (HOPPS)

• Payments to Hospitals

• In a prospective payment system, the payer sets:

– Amount it will pay for services

– Services included in the payment amount (packaging)

– Rate of change in payments over time

• In the hospital setting, CMS considers diagnostic

radiopharmaceuticals (RP) supplies

– RP payment is

packaged

in the procedure payment

• Payment rates based on Ambulatory Payment

Classifications or APCs

(9)

What are APCs?

• Medicare assigns payable CPT procedure and HCPCS codes with

similar resources to a given APC

– CPT® = Current Procedural Terminology assigned by the

American Medical Association (AMA)

• 5-digit numeric codes to describe a procedure

– HCPCS = Healthcare Common Procedure Coding System

• 5-digit alpha-numeric code used for radiopharmaceuticals and

drugs in nuclear medicine

• Payment rate is assigned to the APC and any CPT mapped to that

particular APC will be paid at the same rate, with geographic

(10)

Payment Methodology

In simple terms:

• Rate is based on Medicare claims data from

two years

prior

(e.g., 2016 rate is determined by 2014 claims)

– Because the radiopharmaceuticals assigned to the procedures in

each APC can be widely varying in cost, we often see

underpayments for low volume/high cost procedures

APC Payment Rate =

- Weighted Avg. (TC charges) + Weighted Avg. (RP charges)

– Cost-based relative payment weights using geometric mean costs

• Geometric mean is generally ≤ arithmetic mean

• Better assessment of data when large variations

(11)

HOPPS Executive summary

• Dx RP Reimbursement Continue packaged

• 23 nuclear medicine APCs down to 5 APCs

– Consolidation results in mixed rate changes, impacts Pkg’d expensive Dx RPs

• SPECT MPI procedure payments will slightly decline

• $10 per dose payment for non HEU Tc-99m

• PET procedures are in the same APC (APC 5594 Level 4).

Reimbursement is flat

• Lymphoseek

®

Pass-Through Status expired

• Xofigo – Separate Pmt for Tx RPs; ASP +6%; remains unchanged

• Amyvid – Pass Through Status continues; to be paid at ASP +6%

or WAC+6%; remains unchanged

• Neuraceq and Vizamyl – New Pass-Through Status effective 1Q

2016

(12)

2016 HOPPS – Policies Continued

What did NOT change?

Pass-Through Status (SI “G”) for 1 Dx RP Continues:

– Amyvid, HCPCS A9606 (Eff 1/1/2015; continues 2

nd

Yr.)

– Reimbursement remains at ASP+6% or WAC+6%

Diagnostic Radiopharmaceuticals (w/o Pass-Through Status “N”)

– Packaged into APC Procedure Payment

– APC Offset represents Dx RP portion of APC Procedure Rate

Separate payment for therapeutic RPs & Separately Paid Drugs (Si “K”) –

Either ASP+6% or WAC+6%

Non-HEU add-on payment policy for Tc-99m based RP which are derived

from at least 95% non-HEU sources and priced based on the Full Cost

Recovery Method

– HCPCS code Q9969; APC 1442 (non-HEU Tc-99m Add-on/Dose)

– Payment rate $10; 20% patient co-pay ($2)

Composite APCs - Multiple Imaging remains unchanged

Sequestration 2% Reduction Continues

Coding Edits for RPs – Not Reinstated

(13)

2016 HOPPS Policies – New/Revised

• Overall HOPPS Payments estimated to decrease by (- 0.4%)

– (-0.3%) Conversion Factor Update (2.4% Market Basket minus Adj)

• $73.725 – Hospitals that meet Quality Reporting Requirements

• $72.251 – Hospitals failed to meet Quality Reporting Requirements

– Other policy changes incl. estimated spending for Pass-Through Pmts

• New Nuclear Medicine APC Consolidation & Restructuring

• Transitional Pass-Through Status

– Lymphoseek Pass-Through Ended Dec. 31

st

, 2015

– New Pass-Through Status for 2 Amyloid AD Imaging Agents

• Threshold for Packaged Drugs & Tx RPs @ $100/day

• New Status and Comment Indicators (“J2”, “Q4”, “NP”)

• HOPPS Payment Rate Changes

(14)

NM & PET APC Restructuring and Consolidation

• 23 Nuclear Medicine APCs consolidated

into 5 APCs

(FINAL)

4 APCs Proposed

• NM Imaging & Non-Imaging restructuring finalized:

– Level I – NM & Related Services; APC 5591 ($332.65)

– Level 2 – NM & Related Services; APC 5592 ($441.36)

– Level 3 – NM & Related Services; APC 5593 ($1,108.46)

– Level 4 – NM & Related Services; APC 5594 ($1,285.17)

PET now assigned to Level 4

(originally Level 3 with MPI & others)

– Therapeutic NM; APC 5661 ($249.98)

Proposed – Non-Imaging Nuclear Medicine (Including CPT 38792)

FINAL Only Therapy

• RP therapy administration (Oral & IV) Codes

(15)

HOPPS NM APC Restructuring – CY 2016 FINAL

APC

APC Descriptor

– FINAL Assignments

SI

1Q 2016 Rate

FINAL

5591

Level 1 Nuclear Medicine & Related

Services

S

$332.65

5592

Level 2 Nuclear Medicine & Related

Services

S

$441.36

5593

Level 3 Nuclear Medicine & Related

Services

S

$1,108.46

5594

Level 4 Nuclear Medicine & Related

Services

S

$1,285.17

5661

Therapeutic (Non-Imaging) Nuclear

(16)

NM & PET APC Restructuring and Consolidation

• Impact:

– Consolidation from 23 to 5 APCs will only exacerbate the

problem of high cost, under reimbursed radiopharmaceuticals

– CMS believes

“that the current APC structure is based on

clinical categories that do not necessarily reflect

significant differences in the delivery of these services in

the hospital outpatient department” and the existing

“APCs result in groupings that are unnecessarily narrow

for a PPS”

.

– These new Proposed APC configurations, according to CMS,

are based upon the cost of delivery of these services.

– SPECT MPI and MI PET were kept in different APCs

• SPECT MPI = $1,140.54 (4Q 15) vs $1,108.46 (1Q 16)

• MI PET = $1,286.23 (4Q 15) vs $1,285.17 (1Q 16)

(17)

NM HOPPS Policy Changes - Lymphoseek

• Lymphoseek Transitional Pass-Through Status ended

December 31, 2015.

– Reimbursement for A9520 will be packaged into the APC

Procedure payments

• CPT 38792 (APC 5591) 1Q 2016 Rate = $332.65

• CPT 78195 (APC 5591) 1Q 2016 Rate = $332.65

(18)

Nuclear Cardiology MPI – APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

78451

MPI

,

tomographic (SPECT)

(including attenuation

correction, qualitative or quantitative wall motion, ejection

fraction by first pass or gated technique, additional

quantification, when performed);

single study

, at rest or

stress (exercise or pharmacologic)

0377

5593

$1,140.54

$1,108.46

-2.8%

78452

MPI

,

tomographic (SPECT)

(including attenuation

correction, qualitative or quantitative wall motion, ejection

fraction by first pass or gated technique, additional

quantification, when performed);

multiple studies

, at rest

and/or stress (exercise or pharmacologic) and/or

redistribution and/or rest reinjection

0377

5593

$1,140.54

$1,108.46

-2.8%

78453

MPI

,

planar

(including qualitative or quantitative wall

motion, ejection fraction by first pass or gated technique,

additional quantification, when performed);

single study

, at

rest or stress (exercise or pharmacologic)

0377

5592

$1,140.54

$441.36

-61.3%

78454

MPI

,

planar

(including qualitative or quantitative wall

motion, ejection fraction by first pass or gated technique,

additional quantification, when performed);

multiple

studies

, at rest and/or stress (exercise or pharmacologic)

and/or redistribution and/or rest reinjection

0377

5593

$1,140.54

$1,108.46

-2.8%

93017

Cardiovascular stress test

using maximal or submaximal

treadmill or bicycle exercise, continuous

electrocardiographic monitoring, and/or pharmacological

stress; tracing only, without interpretation and report

0100

5722

Pkg’d or

$238.04

(Q1)

Pkg’d or

$220.35

(Q1)

-7.4%

Note: Q1 – Conditionally packaged; packaged APC payment if billed on the same DOS as a HCPCS code w SI “S”, “T”, or

“V”. Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment

(19)

MPI Packaging – Continues

• Effective January 1, 2014; Continued CY 2016

• Packaging the stress portion & stress agent with payment for MPI

when performed together in the hospital setting

Payment Rates

4Q 2013

4Q 2014 4Q 2015 1Q 2016

Stress Type

Exercise

Dipyridamoze

Lexiscan

Adenosine

Any type

Any type

Any type

78452

$679.68

$679.68

$679.68

$679.68

$1153.62

$1,140.54

$1,108.46

93017

$176.82

$176.82

$176.82

$176.82

Pkg’d

Pkg’d

Pkg’d

Stress Rx

Included

Pkg’d

$213.72

(0.4mg)

$218.76

(60mg)

Pkg’d

Pkg’d

Pkg’d

RP

Pkg’d

Pkg’d

Pkg’d

Pkg’d

Pkg’d

Pkg’d

Pkg’d

(20)

Cardiovascular PET – APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

78459

Myocardial imaging, positron emission tomography

(PET), metabolic evaluation

0308

5594

$1,286.23

$1,285.17

-0.1%

78491

Myocardial imaging, positron emission tomography

(PET), perfusion; single study at rest or stress

0308

5594

$1,286.23

$1,285.17

-0.1%

78492

Myocardial imaging, positron emission tomography

(PET), perfusion; multiple studies at rest and/or stress

0308

5594

$1,286.23

$1,285.17

-0.1%

93017

Cardiovascular stress test

using maximal or

submaximal treadmill or bicycle exercise, continuous

electrocardiographic monitoring, and/or pharmacological

stress; tracing only, without interpretation and report

0100

5722

Pkg’d or

$238.04

(Q1)

Pkg’d or

$220.35

(Q1)

-7.4%

Note:

• Q1 – Conditionally packaged; packaged APC payment if billed on the same DOS as a HCPCS code w SI “S”, “T”, or “V”

• Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment

(21)

Cardiovascular System – APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

0331T

Myocardial sympathetic innervation imaging, planar

qualitative and quantitative assessment;

0377

5593

$1,140.54

$1,108.46

-2.8%

0332T

Myocardial sympathetic innervation imaging, planar

qualitative and quantitative assessment; with

tomographic SPECT

0377

5593

$1,140.54

$1,108.46

-2.8%

78428

Cardiac shunt detection

0398

5591

$373.56

$332.65

-11.0%

78445

Non-cardiac vascular flow imaging (ie, angiography,

venography)

0263

5523

$337.03

$332.65

-1.3%

78456

Acute venous thrombosis imaging, peptide

0317

5593

$813.20

$1,108.46

+36.3%

78457

Venous thrombosis imaging, venogram; unilateral

0263

5592

$337.03

$441.36

+31.0%

78458

Venous thrombosis imaging, venogram; bilateral

0263

5591

$337.03

$332.65

-1.3%

78466

Myocardial imaging, infarct avid, planar; qualitative

or quantitative

0398

5591

$373.56

$332.65

-11.0%

(22)

MUGA Studies – APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

78472

Cardiac blood pool imaging, gated equilibrium; planar,

single study at rest or stress (exercise and/or

pharmacologic), wall motion study plus ejection fraction,

with or without additional quantitative processing

0398

5591

$373.56

$332.65

-11.0%

78473

Cardiac blood pool imaging, gated equilibrium; multiple

studies, wall motion study plus ejection fraction, at rest

and stress (exercise and/or pharmacologic), with or

without additional quantification

0398

5591

$373.56

$332.65

-11.0%

78481

Cardiac blood pool imaging (planar), first pass

technique; single study, at rest or with stress (exercise

and/or pharmacologic), wall motion study plus ejection

fraction, with or without quantification

0398

5592

$373.56

$441.36

+18.1%

78483

Cardiac blood pool imaging (planar), first pass

technique; multiple studies, at rest and with stress

(exercise and/or pharmacologic), wall motion study plus

ejection fraction, with or without quantification

0377

5592

$1,140.54

$441.36

-61.3%

78494

Cardiac blood pool imaging, gated equilibrium, SPECT,

at rest, wall motion study plus ejection fraction, with or

without quantitative processing

0398

5591

$373.56

332.65

-11.0%

+78496

Cardiac blood pool imaging, gated equilibrium, single

study, at rest, with right ventricular ejection fraction by

first pass technique (List separately in addition to code

for primary procedure)

NA

NA

Pkg’d

(“N”)

Pkg’d

(“N”)

NA

Note: Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure

Payment

(23)

Non Cardiac PET – APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

78608

Brain imaging,

PET

; metabolic evaluation

0308

5594

$1,286.23

$1,285.17

-0.1%

78811

PET

imaging; limited area (eg, chest, head/neck)

0308

5594

$1,286.23

$1,285.17

-0.1%

78812

PET

imaging; skull base to mid-thigh

0308

5594

$1,286.23

$1,285.17

-0.1%

78813

PET

imaging; whole body

0308

5594

$1,286.23

$1,285.17

-0.1%

78814

PET

with concurrently acquired computed

tomography (CT) for attenuation correction and

anatomical localization imaging; limited area (eg,

chest, head/neck)

0308

5594

$1,286.23

$1,285.17

-0.1%

78815

PET

with concurrently acquired computed

tomography (CT) for attenuation correction and

anatomical localization imaging; skull base to

mid-thigh

0308

5594

$1,286.23

$1,285.17

-0.1%

78816

PET

with concurrently acquired computed

tomography (CT) for attenuation correction and

anatomical localization imaging; whole body

(24)

Musculosketal Imaging – APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

78300

Bone and/or joint imaging; limited area

0396

5591

$332.31

$332.65

+0.1%

78305

Bone and/or joint imaging; multiple areas

0396

5591

$332.31

$332.65

+0.1%

78306

Bone and/or joint imaging; whole body

0396

5591

$332.31

$332.65

+0.1%

78315

Bone and/or joint imaging; 3 phase study

0396

5591

$332.31

$332.65

+0.1%

78320

Bone and/or joint imaging; tomographic

(SPECT)

0396

5591

$332.31

$332.65

+0.1%

Note: Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment

(25)

Hematopoietic, Reticuloendothelial & Lymphatic

System – APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

78102

Bone marrow imaging; limited area

0400

5591

$369.60

$332.65

-10.0%

78103

Bone marrow imaging; multiple areas

0400

5591

$369.60

$332.65

-10.0%

78104

Bone marrow imaging; whole body

0400

5591

$369.60

$332.65

-10.0%

78122

Whole blood volume determination, including

separate measurement of plasma volume and

red cell volume (radiopharmaceutical

volume-dilution technique)

0393

5592

$628.19

$441.36

-29.7%

78130

Red cell survival study;

0393

5591

$628.19

$332.65

-47.0%

78135

Red cell survival study; differential organ/tissue

kinetics (eg, splenic and/or hepatic

sequestration)

0393

5591

$628.19

$332.65

-47.0%

78185

Spleen imaging only, with or without vascular

flow

0400

5591

$369.60

$332.65

-10.0%

(26)

Gastrointestinal System – APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

78201

Liver imaging; static only

0394

5591

$373.05

$332.65

-10.8%

78202

Liver imaging; with vascular flow

0394

5591

$373.05

$332.65

-10.8%

78205

Liver imaging (SPECT);

0394

5591

$373.05

$332.65

-10.8%

78206

Liver imaging (SPECT); with vascular flow

0394

5591

$373.05

$332.65

-10.8%

78215

Liver and spleen imaging; static only

0394

5591

$373.05

$332.65

-10.8%

78216

Liver and spleen imaging; with vascular flow

0394

5591

$373.05

$332.65

-10.8%

78226

Hepatobiliary system imaging, including gallbladder when

present;

0394

5591

$373.05

$332.65

-10.8%

78227

Hepatobiliary system imaging, including gallbladder when

present; with pharmacologic intervention, including

quantitative measurement(s) when performed

0394

5591

$373.05

$332.65

-10.8%

78262

Gastroesophageal reflux study

0395

5591

$326.95

$332.65

+1.7%

78264

Gastric emptying study (eg, solid. Liquid, or both);

0395

5591

$326.95

$332.65

+1.7%

78265

Gastric emptying study (eg, solid. Liquid, or both); with

small bowel transit

New

5591

New

$336.75

NA

78266

Gastric emptying study (eg, solid. Liquid, or both); with

small bowel and colon transit, multiple days

New

5592

New

$441.36

NA

Note: Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure

Payment

(27)

Respiratory System – APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

78579

Pulmonary ventilation imaging (eg, aerosol or

gas)

0401

5591

$315.89

$332.65

+5.3%

78580

Pulmonary perfusion imaging (eg, particulate)

0401

5591

$315.89

$332.65

+5.3%

78582

Pulmonary ventilation (eg, aerosol or gas) and

perfusion imaging

0378

5592

$440.34

$441.36

+0.2%

78597

Quantitative differential pulmonary perfusion,

including imaging when performed

0401

5591

$315.89

$332.65

+5.3%

78598

Quantitative differential pulmonary perfusion

and ventilation (eg, aerosol or gas), including

imaging when performed

0378

5592

$440.34

$441.36

+0.2%

(28)

Genitourinary System – APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

78700

Kidney imaging morphology;

0404

5591

$420.66

$332.65

-20.9%

78701

Kidney imaging morphology; with vascular flow

0404

5591

$420.66

$332.65

-20.9%

78707

Kidney imaging morphology; with vascular flow and

function, single study without pharmacological

intervention

0404

5592

$420.66

$441.36

+4.9%

78708

Kidney imaging morphology; with vascular flow and

function, single study, with pharmacological intervention

(eg, angiotensin converting enzyme inhibitor and/or

diuretic)

0404

5592

$420.66

$441.36

+4.9%

78709

Kidney imaging morphology; with vascular flow and

function, multiple studies, with and without

pharmacological intervention (eg, angiotensin

converting enzyme inhibitor and/or diuretic)

0404

5592

$420.66

$441.36

+4.9%

78710

Kidney imaging morphology; tomographic (SPECT)

0404

5592

$420.66

$441.36

+4.9%

78725

Kidney function study, non-imaging radioisotopic study

0392

5661

$280.27

$249.98

-10.8%

+78730

Urinary bladder residual study (List separately in

addition to code for primary procedure)

NA

NA

Pkg’d

Pkg’d

NA

78740

Ureteral reflux study (radiopharmaceutical voiding

cystogram)

0404

5591

$420.66

$332.65

-20.9%

78761

Testicular imaging with vascular flow

0404

5591

$420.66

$332.65

-20.9%

Note: Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment

28

(29)

Other (Abscess, Tumor, etc.)

APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

78800

Radiopharmaceutical localization of tumor or distribution

of radiopharmaceutical agent(s); limited area

0406

5591

$377.33

$332.65

-11.8%

78801

Radiopharmaceutical localization of tumor or distribution

of radiopharmaceutical agent(s); multiple areas

0406

5591

$377.33

$332.65

-11.8%

78802

Radiopharmaceutical localization of tumor or distribution

of radiopharmaceutical agent(s); whole body, single day

imaging

0414

5592

$706.73

$441.36

-37.5%

78803

Radiopharmaceutical localization of tumor or distribution

of radiopharmaceutical agent(s); tomographic (SPECT)

0414

5592

$706.73

$441.36

-37.5%

78804

Radiopharmaceutical localization of tumor or distribution

of radiopharmaceutical agent(s); whole body, requiring 2

or more days imaging

0408

5593

$1,188.74

$1,108.46

-6.8%

78805

Radiopharmaceutical localization of inflammatory

process; limited area

0414

5593

$706.73

$1,108.46

+56.8%

78806

Radiopharmaceutical localization of inflammatory

process; whole body

0414

5593

$706.73

$1,108.46

+56.8%

(30)

Therapeutic – APC & Rate Changes

CPT

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

79005

Radiopharmaceutical therapy, by oral

administration

0407

5661

$276.93

$249.98

-9.7%

79101

Radiopharmaceutical therapy, by intravenous

administration

0407

5661

$276.93

$249.98

-9.7%

79200

Radiopharmaceutical therapy, by intracavitary

administration

0407

5661

$276.93

$249.98

-9.7%

79300

Radiopharmaceutical therapy, by interstitial

radioactive colloid administration

0407

5661

$276.93

$249.98

-9.7%

79403

Radiopharmaceutical therapy, radiolabeled

monoclonal antibody by intravenous infusion

0407

5661

$276.93

$249.98

-9.7%

79440

Radiopharmaceutical therapy, by intra-articular

administration

0407

5661

$276.93

$249.98

-9.7%

79445

Radiopharmaceutical therapy, by intra-arterial

particulate administration

0407

5661

$276.93

$249.98

-9.7%

Note: Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment

(31)

Therapeutic RPs – APC & Rate Changes

HCPCS

Code

Descriptor

APC

HOPPS Rate

%

Change

2015

2016

4Q 2015

1Q 2016

A9517

Iodine I-131 sodium iodide capsule(s),

therapeutic, per millicurie

1064

1064

$40.70

$40.70

0.0%

A9530

Iodine I-131 sodium iodide solution,

therapeutic, per millicurie

1150

1150

$10.28

$10.28

0.0%

A9543

Yttrium Y-90 ibritumomab tiuxetan,

therapeutic, per treatment dose, up to 40

millicuries (Trade Name – Zevalin)

1643

1643

$46,304.42

$46,176.12

-0.3%

A9563

Sodium phosphate P-32, therapeutic, per

millicurie

1675

1675

$213.56

$213.56

0.0%

A9564

Chromic phosphate P-32 suspension,

therapeutic, per millicurie

1676

1676

$906.62

$906.62

0.0%

A9600

Strontium Sr-89 chloride, therapeutic, per

millicurie (Trade Name – Metastron)

0701

0701

$1,160.34

$1,159.92

-0.04%

A9604

Samarium Sm-153 lexidronam,

therapeutic, per treatment dose, up to 150

millicuries (Trade Name – Quadramet)

(32)

HOPPS Coding Tips

Don’t forget to bill for Dx RPs

You can use HCPCS Level II code Q9969 to obtain $10 per dose reimbursement when

using non-highly enriched Uranium sourced Tc-99m.

Please be aware that you may be able to obtain HOPPS reimbursement for PET Amyloid

imaging agents under Coverage with Evidence Development (CED) when involved in CMS

approved PET clinical studies (4 Trials including IDEAS clinical trial accepting applications)

Note: HCPCS Level II “C” codes (for new PET Beta Amyloid imaging agents) can only be

used in the hospital outpatient department setting.

Reimbursement for all Dx RPs (not on Pass-Through Status) are packaged into the HOPPS

APC procedure.

Note: Dx RPs (even though packaged) are reimbursed. The APC Offset is the portion of

the HOPPS Rate that represents the Dx DP.

ICD-10 Dx Codes must be used as of Oct 1

st

, 2015.

Hospital providers should update their Charge Description Masters (CDMs) with new codes

& charges to reflect changes in costs due to new technology, new supplier contracts, payer

coverage & coding guidelines minimum of once/year (Oct to Dec recommended).

Providers should be aware that there are new & revised CPT codes for Gastric Emptying

Imaging Studies.

(33)

MEDICARE PHYSICIAN FEE

SCHEDULE (MPFS)

(34)

MPFS executive summary

• Diagnostic radiopharmaceuticals continue to be paid separately.

– Acquisition Cost, WAC and/or set fee schedule

– Lymphoseek

®

may be reimbursed separately

• SGR was repealed 2015

– +0.5% CF Increase allowed by statute for CY 2016

– CY 2016 CF Final = $35.8043

– CF slight decrease ~ (-0.36%) due to offsets

• Most procedure allowables resulted in small changes

• SPECT MPI procedure allowables remain ~ flat.

• HCPCS Level II “C” codes cannot be used in the MPFS Part B Setting

• Coverage and reimbursement locally determined at the MAC level

• Implementation of AUC for advanced imaging has been delayed

• CPT 78306 identified as potentially mis-valued code; CPT 78452

removed from the list.

(35)

MPFS Overview

• Payments to:

– Services performed in the clinic or office setting

– Physician professional services

• Each procedure may be billed in the following ways:

– Technical Component (TC) only

• covers equipment, supplies, office expense, non-physician staff

– Professional Component (26) only

• covers physician professional services

(36)

MPFS Payment Methodology

• Payment methodology:

– Resource Based Relative Value Scale (RBRVS)

– Each CPT is assigned a Relative Value Unit (RVU)

– RVU = a numerical value assigned to procedures that reflects

the resources required to provide the service under the

RBRVS system

– Each RVU is multiplied by a geographic practice cost index

and the year’s conversion factor to determine the local

payment rate.

Relative Value Geographic Practice Conversion Local Medicare

Units (RVU) X Cost Index (GPCI) X Factor (CF) = Payment Rate

(37)

2016 PFS Changes Affecting NM Procedures:

Sustainable Growth Rate (SGR) Formula

Introduced in Balanced Budget Act of 1997

First applied 1998

Intended to control the growth in aggregate Medicare expenditures for

physician services

Statutory requirement* that CMS adjusts the Medicare physician fee

schedule with an annual update, which includes the new Conversion

Factor (CF)

Medicare Access and CHIP Reauthorization Act of 2015 –

“SGR”

Finally Fixed

– SGR Formula repealed by an act of congress

– Increased the Conversion Factor Effective July 1, 2015

– Provided for 0.5% Conversion Factor Increase Annually

(38)

Conversion Factor & SGR Fix

Conversion Factor for 2015 & 2016:

Mandated by the “Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

CF 2015

(Jan – Jun)

CF 2015

(July

– Dec)

CF 2016

(Proposed)

CF 2016

FINAL

Change

$35.7547

$35.9335

$36.1096

35.8043

-0.36%

38

(39)

CY 2016 MPFS Policies (cont)

• 2% Sequestration Continues

• DRA Cap on the Technical and Global

Allowables for imaging procedures

(40)

Radiopharmaceuticals (RP) and Drugs

Both are paid separately

Radiopharmaceuticals:

Based on invoice or up to a maximum allowable a

contractor has set; typically 95% of Average Wholesale

Price (AWP)

– Some contractors post radiopharmaceutical fee

schedules online

Drugs used in nuclear medicine:

Based on Average Selling Price (ASP) + 6%

Medicare publishes an ASP Pricing file with the payment

rates quarterly

(41)

Multiple Procedure Payment Reductions

(MPPR)

NO NEW

Multiple Procedure Payment Reductions

in 2016!

(42)

CY 2016 MPFS FINAL Rule Highlights

Proposed Rule:

CMS must establish AUC by November 15, 2015

and must have AUC consultation implemented by January 1, 2017.

This applies to advanced diagnostic imaging services, MRI, CT and

nuclear medicine and PET. Note: the AUC goal is decrease use of

expensive imaging procedures when they are not necessary for

patient care.

Final Rule:

CMS has delayed implementation of the Proposed

AUC for advanced imaging services.

• Anticipates adoption of claims-based reporting requirements in CY

2017 & 2018 Rulemaking Cycles

(43)

CY 2016 MPFS FINAL Rule Highlights (cont)

• Potentially mis-valued codes. Selected codes used a high

expenditure screen ($10 Million or more) for “codes that account for

the majority of spending under the PFS.”

– Top 20 codes by specialty based upon Medicare allowed charges

– CMS Finalized a list of 103 Codes including CPT 78306

• CPT 78306 whole body bone imaging

– CMS removed CPT 78452 SPECT MPI from the list based upon

comments that selection criteria was not met; i.e., CPT 78452 was

reviewed since CY 2010

– SNMMI Commented: No changes in physician work or technology have

taken place since the last review to support review for CPT 78306

– SNMMI stated concern that high volume screens should not be sole

basis for review

(44)

Nuclear Medicine – SPECT MPI

MPFS Global National Rates (GL)

CPT

Code

Status

Descriptor

4Q 2015

Rates

1Q 2016

Rates

%

Change

78451

A

MPI

,

tomographic (SPECT)

(including attenuation correction,

qualitative or quantitative wall motion, ejection fraction by first

pass or gated technique, additional quantification, when

performed);

single study

, at rest or stress (exercise or

pharmacologic)

$355.74

$355.89

+0.04%

78452

A

MPI

,

tomographic (SPECT)

(including attenuation correction,

qualitative or quantitative wall motion, ejection fraction by first

pass or gated technique, additional quantification, when

performed);

multiple studies

, at rest and/or stress (exercise or

pharmacologic) and/or redistribution and/or rest reinjection

$492.65

$493.03

+0.08%

78453

A

MPI

,

planar

(including qualitative or quantitative wall motion,

ejection fraction by first pass or gated technique, additional

quantification, when performed);

single study

, at rest or stress

(exercise or pharmacologic)

$317.29

$317.23

-0.02%

78454

A

MPI

,

planar

(including qualitative or quantitative wall motion,

ejection fraction by first pass or gated technique, additional

quantification, when performed);

multiple studies

, at rest and/or

stress (exercise or pharmacologic) and/or redistribution and/or

rest reinjection

$454.20

$456.15

+0.43%

93015

A

Cardiovascular stress

test using maximal or submaximal treadmill

or bicycle exercise, continuous electrocardiographic monitoring,

and/or pharmacological stress; with supervision, interpretation and

report

$77.26

$76.98

-0.36%

Notes: Dx Radiopharmaceutical, Stress Agents paid separately; CPT 93015 billed separately

(45)

Lymphoseek

®

MPFS Global National

Allowables

CPT Code

Status

Descriptor

4Q 2015

Rates

1Q 2016

Rates

%

Change

38792

A

Injection procedure; radioactive

tracer for identification of sentinel

node

$40.96

$41.17

+0.51%

78195

A

Lymphatics and lymph nodes

imaging

$371.19

$371.29

+0.03%

78195-26

A

Lymphatics and lymph nodes

imaging

$60.01

$60.15

+0.23%

78195-TC

A

Lymphatics and lymph nodes

imaging

$311.18

$311.14

-0.01%

Notes:

Dx Radiopharmaceutical paid separately (Acquisition Cost; Fee Schedule; or, WAC/AWP)

Coverage determined locally by each Medicare Administrative Contractor (MAC)

(46)

MPFS Coding Tips

Dx RPs are reimbursed separately in the physician office, Independent

Diagnostic Testing Facility (IDTF) and free-standing practice provider settings.

Separate reimbursement for Dx RPs is based upon either acquisition cost, WAC,

and/or set fee schedule.

Coverage can vary for a given procedure depending on the Medicare

Administrative Contractor (MAC). ICD-10 Dx medical necessity codes can vary.

Coverage for Dx RPs (including Lymphoseek) may vary depending on the MAC

and even at the state level.

Reimbursement for advanced imaging procedures (including NM) is capped at

the HOPPS reimbursement level by the DRA.

Reimbursement rates and allowables are adjusted for geography using the GPCI

Note: HCPCS Level II “C” codes (for new PET Beta Amyloid imaging agents)

can only be used in the hospital outpatient department setting. Use the

appropriate “A” code in the Physician Office/Free-Standing setting.

– AmyVid (A9586); Neuraceq & Vizamyl (A9599)

(47)

Links for more information

2016 FINAL Hospital Outpatient Prospective Payment System

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalOutpatientPPS/Hospital-Outpatient-

Regulations-and-Notices-Items/CMS-1633-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=desc

ending

2016 FINAL Physician Fee Schedule (MPFS)

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-

Items/CMS-1631-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=desc

ending

(48)

Prepared by: NMD Healthcare Consulting, on behalf of Cardinal

Health, in response to your specific reimbursement concerns.

Reimbursement information is provided as general coding and

payment information. This information is not intended to replace or

serve as substitute for your duty, your customer’s and/or the

provider’s responsibility to verify that such information is proper for

your particular circumstances. Any codes reported should accurately

reflect the procedures performed and the patient’s conditions. You

should consult with local payers to confirm compliance with local

policies, and otherwise review and confirm reimbursement policies

with your own legal or other professional advisors.

Disclaimer

(49)
(50)

Q

&

A

(51)

Acronyms

APC – Ambulatory Payment Classification

APC Offset – APC payment percentage representing radiopharmaceutical

ASC – Ambulatory Surgical Center

AWP – Average Wholesale Price

CMS – Centers for Medicare & Medicaid Services

CPT® – Current Procedural Terminology (procedure codes)

DRGs – Diagnosis Related Groups

Dx – Diagnosis

FSC – Filtered sulfur colloid

HCPCS – Healthcare Common Procedure Coding System

(materials/services)

HOPPS – Hospital Outpatient Prospective Payment System (Part A)

(52)

Acronyms (continued)

LSK – Lymphoseek®

MAC – Medicare Administrative Contractor

MACRA – Medicare Access and CHIP Reauthorization Act of 2015

MPFS – Medicare Physician Fee Schedule (Part B)

NDC – National Drug Code

OIG – Office of Inspector General

PET – Positron Emission Tomography

PI – Prescribing Information

RP – Radiopharmaceutical

RVU – Relative Value Unit

SNMMI – Society of Nuclear Medicine & Molecular Imaging

SGR – Sustainable Growth Rate

Figure

Updating...

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