ACR Issues Analysis of Final HOPPS Rule for 2016
The Centers for Medicare and Medicaid Services (CMS) released its final rule for calendar year (CY) 2016 changes to the Hospital Outpatient Prospective Payment System (HOPPS) on Oct. 30, 2015. Any comments the American College of Radiology (ACR) would like CMS to consider must be submitted within the 60-day comment period ending on Dec. 29, 2015. Following is a detailed summary of the Final Rule (FR).
HOPPS Conversion Factor
Despite heavy opposition by numerous commenters, CMS has elected to move forward with their proposal to adjust the CY 2016 conversion factor by -2.0 percent. The stated reasoning is to make a budget neutral adjustment to recoup funds resulting from overpayment of Outpatient Prospective Payment System (OPPS) services for laboratory tests in CY 2015. Therefore the HOPPS conversion factor for 2016 will be $73.725 and the adjusted conversion factor (CF) for hospitals that do not report measures will be 2 percent lower at $72.251.
Expansion of Comprehensive APCs
In the CY 2014 OPPS/ Ambulatory Surgical Center (ASC) final rule with comment period, CMS finalized a comprehensive payment policy that packages payment for adjunctive and secondary items, services and procedures at the claim level. For these single encounter payments, the HOPPS version of episodes-of-care moved package planning and preparation services into the most costly primary procedure. Services excluded from the Comprehensive Ambulatory Payment Classifications (C-APC) policy include those that cannot by statute be paid for under the OPPS and services that are required by statute that must be separately paid including mammography and brachytherapy seeds. The CY 2014 OPPS/ASC final rule included a provision for 25 C-APC’s and with the CY 2016 rule CMS moved forward with the establishment of 10 new C-APC’s. The ACR has commented extensively on this issue and maintains that the C-APC methodology represents a continued insensitivity to clinical
complexity. As such, in response to the proposed rule, the ACR requested that CMS consider the use of tertiary codes to assign complexity for the C-APCs that represent more complex care, such as endovascular revascularization. CMS stated that it did not believe that adjusting for the
complexity of a claim with more than two primary “J1” codes served the purpose of the policy. ACR believes that CMS failed to comprehend the potential purpose and impact of utilizing tertiary codes for the capture of deeper levels of complexity and costs.
Stereotactic Radiosurgery (SRS) C-APC 5631
The American Taxpayer Relief Act (ATRA) requires equal payment for SRS delivered by Cobalt-60 based or LINAC-based technology. CMS has elected to move forward with their proposal to change payment for SRS by identifying services billed differentially for Healthcare Common Procedure Coding System (HCPCS) codes 77371 and 77372 on the same claim and on claims one month prior to delivery of SRS services. Any codes CMS removes from the C-APC bundle will receive separate payment even when appearing with a “J1” procedure code (HCPCS code 77371 or 77372) on the same claim for both CY 2016 and CY 2017. CMS is establishing a
HCPCS “CP” modifier to be reported with every code that is adjunctive to a comprehensive stereotactic radiosurgery service. The use of this modifier is effective Jan. 1, 2016. Once CMS has gathered data on the ancillary services using the new modifier, they may consider these services part of the SRS C-APC and discontinue separate payment in future years. For now, CMS will not adopt a policy requiring a modifier for the identification of separately reported adjunctive services with any other C-APC, but mentions that they may elect do so in the future. Payment of Drugs, Biologicals and Radiopharmaceuticals
CMS has elected to continue to pay for the acquisition and pharmacy overhead costs of separately payable drugs and biologicals that do not have pass-through status at the statutory default of average sales price (ASP) plus 6 percent.
Pass-Through Payments
For CY 2016 CMS is moving forward with several novel payment offsets for products that may be approved for pass-through status throughout the year including those for contrast, stress agents and diagnostic radiopharmaceuticals. Currently, there is only one contrast agent with pass-through payment status under the OPPS. HCPCS code Q9950 (Injection, sulfur
hexafluoride lipid microsphere, per ml) and it was granted pass-through payment status as
recently as Oct. 1, 2015. The rationale for providing payment offsets for products that have yet to be approved stems from CMS seeking to avoid inadvertently duplicate payments similar to those responsible for the proposed net downward adjustment to the CY 2016 HOPPS conversion factor.
Packaging Threshold
CMS has elected to raise the packaging threshold for therapeutic radiopharmaceuticals from $95 to $100. In addition, CMS is moving forward with their proposal to package those drugs with a per-day cost less than or equal to $100, and to identify those with a per day cost greater than $100 which will be paid separately. All non-pass-through, separately payable therapeutic radiopharmaceuticals will be paid at ASP plus 6 percent.
Proposed Treatment of New and Revised CY 2016 Category I and III Current Procedural Terminology (CPT) Codes That Will Be Effective Jan. 1, 2016
As stated in the proposed rule, CMS will be assigning APC’s and Status Indicators for new and revised Category I and III CPT codes as long as they are made available to the public by the American Medical Association (AMA) in a timely manner. They have additionally finalized their proposal to make interim APC and status indicator assignments for CPT codes that are not available in time for the proposed rule and that describe wholly new services (such as new technologies or new surgical procedures), solicit public comments, and finalize the specific APC and status indicator assignments for those codes in the following year’s final rule.
With a single exception, CMS is moving forward with its proposal to restructure and renumber nine of the APC clinical families including those for Excision/Biopsy, Incision and Drainage, Radiology, and Nuclear Medicine Services. This restructure decreases the number of Imaging APC’s from 54 to 26. In keeping with their insistence that previous APC groupings were too granular, CMS has elected to combine the Excision/Biopsy APC’s with those for Incision and Drainage and to place the nuclear medicine APCs under the diagnostic radiology category (including X-Ray, CT, MRI, and ultrasound). The single exception to the reduction of total groupings was the creation of a fourth Nuclear Medicine APC to separate out the PET studies which many have commented have much higher costs than other nuclear medicine studies (e.g. SPECT). Additionally, it was noted by the ACR that some codes did not fit neatly in their respective modalities and the ACR proposed alternate APC family placement. Below you will find those suggestions. The furthest right-hand column represents the APC placement finalized in the CY 2016 OPPS FR.
Table 1 - HCPCS/CPT Codes that Change APC Family
CMS believes that the APC restructure simplifies and makes more understandable the OPPS APC structure and ostensibly reduces resource overlap by decreasing the total APC’s. CMS also states that the new APC structure will more readily accept future services under these broader groupings. CMS is also proposing to renumber several families of APCs to provide consecutive APC numbers for consecutive APC levels within a clinical family for improved identification of APCs and ease of understanding the APC groupings. These new placements alter the pricing of many imaging studies, some significantly.
Below you will find a series of tables detailing the proposed placement of HCPCS/CPT codes into APC families (CMS 2016 P APC), the ACR proposal for code placement and the furthest right-hand column represents the APC placement finalized in the CY 2016 OPPS FR.
HCPC
S/CPT Short Descriptor
2016P
APC APC Descriptor
Proposed
APC APC Descriptor
2016 F APC 70559
Mri brain w/o &
w/dye 5582
MRI MRA w wo Contrast
Level 2 5526
Level 6 X-Ray and Related
Services 5526
74261
Ct colonography
dx 5521
Level 1 X-Ray and Related
Services 5570
Computed Tomography without
Contrast 5570
75572
CT hrt w/3d
image 5523
Level 3 X-Ray and Related
Services 5571
Level 1 Computed Tomography with Contrast and Computed
Tomography Angiography 5571
75559
Cardiac mri
w/stress img 5581
Level 1 Magnetic Resonance Imaging and Magnetic Resonance Angiography with
Contrast 5592
Level 2 Nuclear Medicine and
Related Services 5592
75557
Cardiac mri for
morph 5581
Level 1 Magnetic Resonance Imaging and Magnetic Resonance Angiography with
Contrast 5593
Level 3 Nuclear Medicine and
Related Services 5581
X-Ray APCs
The ACR was disappointed to learn that code 75705 (Artery X-Rays spine) was left in APC 5526 Level 6 X-Ray and Related Services, and maintains that this code should be moved to a higher cost category in a different APC so that hospitals can be paid to cover their costs.
Table 3 – X-Ray and Related Services HCPCS/CPT that Decreased APC Levels
HCPCS/C PT Short Descriptor CMS 2016 P APC ACR Proposed APC Final APC
70190 X-ray exam of eye sockets 5522 5521 5521
74210 Contrst x-ray exam of throat 5522 5521 5522
72040 X-ray exam neck spine 203 vw 5522 5521 5522
76101 Complex body section x-ray 5523 5522 5522
78458 Vein thrombosis images bilat 5524 5523 5591
74470 X-ray exam of kidney lesion 5525 5524 5524
75898 Follow-up angiography 5526 5525 5525
75827 Vein x-ray chest 5526 5525 5525
Table 2 - X-Ray and Related Services HCPCS/CPT that Increased APC Levels
CT Family
The ACR had requested that when the APC’s were reorganized that the CT family would be divided by CT with contrast (Level I), CT without contrast (Level II) and CT without followed
HCPCS/CPT Short Descriptor CMS 2016 P APC ACR Proposed APC Final APC
70370 Throat x-ray & fluoroscopy 5521 5522 5521
71030 Chest x-ray 4/> views 5521 5522 5521
72200 X-ray exam si joints 5521 5522 5522
76496 Fluoroscopic procedure 5521 5522 5521
72050 X-ray exam neck spine 4/5vws 5522 5523 5522
72110 X-ray exam 1-2 neck spine 4/vws 5522 5523 5522
72074 X-ray exam thorac spine 4/>vw 5522 5523 5522
77074 X-rays bone survey limited 5522 5523 5522
74240 X-ray upper gi delay w/o kub 5522 5523 5522
76010 X-ray nose to rectum 5522 5523 5523
72052 X-ray exam neck spine 6/>vws 5522 5523 5522
74246 Contrst x-ray uppr gi tract 5522 5523 5522
76120 Cine/videos x-rays 5522 5523 5522
74270 Contrast x-ray exam of colon 5522 5523 5522
74241 X-ray upper gi delay w/kub 5522 5523 5522
70371 Speech evaluation complex 5522 5523 5522
77075 X-rays bone survey complete 5522 5523 5522
74247 Contrst x-ray uppr gi tract 5522 5523 5522
49465 Fluoro exam of g/colon tube 5522 5523 5522
73092 X-ray exam of arm infant 5522 5523 5522
70320 Full Mouth x-ray of teeth 5522 5523 5523
74260 X-ray exam of small bowel 5522 5523 5523
70310 X-ray exam of teeth 5522 5523 5523
74290 Contrast x-ray gallbladder 5522 5523 5523
74430 Contrast x-ray bladder 5523 5524 5523
74450 X-ray urethra/bladder 5523 5524 5523
74455 X-ray urethra/bladder 5523 5524 5524
74740 X-ray female genital tract 5523 5524 5524
C9733 Non-opthalmic fva 5523 5524 5524
G0120 Colon ca scrn; barium enema 5524 5525 5524
74445 X-ray exam of penis 5524 5525 5524
78457 Venous thrombosis imaging 5524 5524 5592
78456 Acute venous thrombus imaging 5524 5525 5593
by with (Level III). CMS elected to finalize those categories but did not adhere to the suggested Geometric Mean calculations.
Table 4 - CT with and without Contrast Calculation of APC Geo-mean Post Restructuring
ACR also recommended the following changes to the placement of HCPCS/CPT codes in the CT Family of APC’s. The furthest right-hand column represents the APC placement finalized in the CY 2016 OPPS FR.
Table 5 - CT with Contrast and CT Angiography HCPCS/CPT that Increased APC Levels
APC Title CMS Geometric Mean ACR Proposed Geometric Mean CMS Proposed Payment Rate Finalized Payment Rate 5570 Computed Tomography without Contrast $ 124.81 $ 124.73 $ 118.15 $ 112.49
5571 Level 1 Computed Tomography with Contrast and
Computed Tomography Angiography $ 258.10 $ 293.13 $ 244.31 $ 236.86
5572 Leve 2 Computed Tomography with Contrast and
Computed Tomography Angiography $ 343.70 $ 319.09 $ 325.34 $ 347.72
HCPCS/ CPT Short Descriptor CMS 2016 P APC ACR Proposed APC Final APC
70470 Ct head/brain w/o & w/dye 5571 5572 5571
70482 Ct orbit/ear/fossa w/o & w/dye 5571 5572 5571
70488 Ct maxillofacial w/o &w/dye 5571 5572 5571
70492 Ct sft tsue nck w/o & w/dye 5571 5572 5571
70496 Ct angiography head 5571 5572 5571
70498 Ct angiography neck 5571 5572 5571
71275 Ct angiography chest 5571 5572 5571
72127 Ct neck spine w/o & w/dye 5571 5572 5571
72130 Ct chest spine w/o & w/dye 5571 5572 5571
72133 Ct lumbar spine w/o & w/dye 5571 5572 5571
72191 Ct angiograph pelv w/o & w/dye 5571 5572 5571
72194 Ct pelvis w/o & w/dye 5571 5572 5571
73202 Ct uppr extremity w/o & w/dye 5571 5572 5571
73206 Ct angio uppr extrm w/o & w/dye 5571 5572 5571
73702 Ct lwr extremity w/o & w/dye 5571 5572 5571
73706 Ct angio lwr extr w/o & w/dye 5571 5572 5571
74170 Ct abdomen w/o & w/dye 5571 5572 5571
74175 Ct angio abdom w/o & w/dye 5571 5572 5571
75574 Ct angio hrt w/3d image 5571 5572 5571
Table 6 - CT with Contrast and CT Angiography HCPCS/CPT that Lowered APC Levels
MR Family
ACR recommended the following changes to the placement of HCPCS/CPT codes in the MR Family of APC’s. The furthest right-hand column represents the APC placement finalized in the CY 2016 OPPS FR.
Table 7 - MRI and MR Angiography HCPCS/CPT that Increased APC Levels
Ultrasound Family
The ACR recommended the following changes to the placement of HCPCS/CPT codes in the Ultrasound Family of APC’s which we believed fit better clinically and with respect to resources. The furthest right-hand column represents the APC placement finalized in the CY 2016 OPPS FR. HCPCS/ CPT Short Descriptor CMS 2016 P APC ACR Proposed APC Final APC
72126 Ct neck spine w/dye 5572 5571 5572
73201 CT upper extremity w/dye 5572 5571 5572
74177 Ct abd & pelv w/contrast 5572 5571 5572
HCPCS/ CPT Short Descriptor CMS 2016 P APC ACR Proposed APC Final APC
70544 Mr angiography head w/o dye 5581 5583 5581
70547 Mr angiography neck w/o dye 5581 5583 5581
70545 Mr angiography head w/ dye 5582 5583 5582
70546 Mr angiography head w/o and w/ dye 5582 5583 5582
70548 Mr angiography neck w/ dye 5582 5583 5582
70549 Mr angiography neck w/o and w/ dye 5582 5583 5582
C8902 Mra w/o fol w/cont, abd 5582 5583 5582
C8911 Mra w/o fol w/cont, chest 5582 5583 5582
C8914 Mra w/o fol w/cont, lwr ext 5582 5583 5582
C8920 Mra w/o fol w/cont, pelvis 5582 5583 5582
C8933 Mra w/o&w/dye, spinal canal 5582 5583 5582
Table 8 - Ultrasound HCPCS/CPT that Increased APC Levels HCPCS/CPT Short Descriptor CMS 2016 P APC ACR Proposed APC Final APC 93979 Vascular Study 5531 5532 5532 76513
Echo exam of eye water
bath 5531 5532 5532
76536 Us exam of head and neck 5531 5532 5532
76815 Ob us limited fetus(s) 5531 5532 5532
76775 Us exam abdo back wall lim 5531 5532 5532
76870 Us exam scrotum 5531 5532 5532
76817 Transvaginal us obstetric 5531 5532 5532
93890 Tcd vasoreactivity study 5531 5532 5532
91200 Liver elastography 5531 5532 5532
Table 9 - Ultrasound HCPCS/CPT that Decreased APC Levels
Nuclear Medicine
In response to comments, CMS elected to add a fourth level to the nuclear medicine and related services group (APC 5594 (Level 4 Nuclear Medicine and Related Services), and are reassigning the PET procedures that were proposed to be assigned to APC 5593 (Level 3 Nuclear Medicine and Related Services) to APC 5594. While they state that this APC is not necessarily limited to only PET procedures, currently all those codes residing in APC 5594 describe PET procedures. Excision/Biopsy and Incision and Drainage Procedures
The ACR recommended the following changes to the placement of HCPCS/CPT codes in the Excision/Biopsy and Incision and Drainage Family of APC’s which we believed fit better
HCPCS/ CPT Short Descriptor CMS 2016 P APC ACR Proposed APC Final APC
76705 Echo exam of abdomen 5532 5531 5532
76801 Ob us < 14 wks single fetus 5532 5531 5532
76830 Transvaginal us non-ob 5532 5531 5532
76872 Us transrectal 5532 5531 5532
76881 Us xtr non-vasc complete 5532 5531 5532
93888 Intracranial limited study 5532 5531 5532
clinically and with respect to resources. The furthest right-hand column represents the APC placement finalized in the CY 2016 OPPS FR.
Table 10 – Excision/Biopsy/Incision and Drainage HCPCS/CPT that Increased APC Level
HCPCS/CPT Short Descriptor CMS 2016 P APC ACR Proposed APC Final APC
11750 Removal of nail bed 5071 5072 5071
38300 Drainage lymph node lesion 5071 5073 5074
62269 Needle biopsy spinal cord 5071 5073 5073
69005 Drain external ear lesion 5071 5073 5074
15999 Removal of pressure sore 5071 5074 5071
23931 Drainage of arm bursa 5071 5074 5074
47399 Liver surgery procedure 5071 5074 5071
48999 Pancreas surgery procedure 5071 5074 5071
57022 I & d vaginal hematoma pp 5071 5074 5074
11603 Exc tr-ext mal+mrg 2.1-3 cm 5072 5073 5073
11641 Exc f/e/e/n/l mal+mrg 0.6-1 5072 5073 5072
11642 Exc f/e/e/n/l mal+mrg 1.1-2 5072 5073 5072
15782 Dermabrasion other than face 5072 5073 5074
21930 Exc back les sc < 3 cm 5073 5074 5074
Vascular Procedures
The ACR recommended that CMS make the following revisions to the vascular APCs as we believed they provided a better fit clinically and with respect to resources. The furthest right-hand column represents the APC placement finalized in the CY 2016 OPPS FR.
Table 11 - Vascular Procedures HCPCS/CPT that Increased APC Levels
Cardiac MR HCPCS/ CPT Short Descriptor CMS 2016 P APC ACR Proposed APC Final APC
37799 Vascular surgery procedure 5181 5182 5181
93505 Biopsy of heart lining 5181 5182 5182
37501 Vascular edoscopy procedure 5181 5183 5181
36566 Insert tunneled cv cath 5182 5183 5183
The ACR was glad to see that CMS heeded the request by the Society for Cardiovascular
Magnetic Resonance’s (SCMR) to move CPT code 75563 (Cardiac MR) from the proposed APC 5592 to the Level III nuclear medicine APC 5593. Cardiac MR is clinically similar to the nuclear cardiology stress perfusion codes that CMS has placed in APC 5593.
APC Assignment of Lung Cancer Screening Codes
On Feb. 5, 2015, CMS issued a National Coverage Determination (NCD) for the coverage of lung cancer screening with low-dose computed tomography (LDCT) under Medicare. Under the HOPPS CY 2016 Final Rule CMS has defined the APC placement of the HCPCS codes that describe these services. HCPCS code G0297 (LDCT scan) for lung cancer screening has been assigned to APC 5570 at a payment rate of $112.49. HCPCS code G0296 (Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan has been assigned to APC 5822 at a payment rate of $69.65. The ACR agrees with CMS’ placement of G0297. It fits clinically and with respect to resource use with its diagnostic counterpart code 71250 (CT thorax without contrast). The APC placements and payment rates of these new codes are effective from the Feb. 5, 2015 NCD effective date and may be billed under OPPS Jan. 1, 2016.
Table 12: APC Placement and Payment Rates of Lung Cancer Screening Codes
Changes for Payment for Computed Tomography (CT) When Not in Compliance with XR-29-2013
Section 218(a)(1) of the Protecting Access to Medicare Act of 2014 (PAMA) mandates that for the technical component of applicable computed tomography services paid under the physician fee schedule and HOPPS that a five percent reduction in 2016 and a 15 percent reduction in 2017 and subsequent years be made for services furnished using equipment that does not meet the requirements of the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013, entitled “Standard Attributes on CT Equipment Related to Dose Optimization and Management.” Below you will find a table of applicable CT services and the estimated payment rates for 2016 and beyond.
Table 13 - Applicable CT Services and Estimated Payment Rates HCPCS
Code
Short Descriptor APC Payment Rate Estimated 5% 2016 Adjustment Estimated 15% 2017 Adjustment 74176 Ct abd & pelvis w/o
contrast
5523 $191.97 $182.37 $163.17 70450 Ct head/brain w/o dye 5570 $112.49 $106.87 $95.62
HCPCS Code Short De scriptor APC Group Name Payme nt Rate
G0296 Visit to determ ldct
elig 5822 Level 2 Health and Behavior Services $69.65
G0297 Ldct for lung ca
70480 Ct orbit/ear/fossa w/o dye 5570 $112.49 $106.87 $95.62 70486 Ct maxillofacial w/o dye 5570 $112.49 $106.87 $95.62 70490 Ct soft tissue neck
w/o dye
5570 $112.49 $106.87 $95.62 71250 Ct thorax w/o dye 5570 $112.49 $106.87 $95.62 72125 Ct neck spine w/o dye 5570 $112.49 $106.87 $95.62 72128 Ct chest spine w/o
dye
5570 $112.49 $106.87 $95.62 72131 Ct lumbar spine w/o
dye
5570 $112.49 $106.87 $95.62 72192 Ct pelvis w/o dye 5570 $112.49 $106.87 $95.62 73200 Ct upper extremity w/o dye 5570 $112.49 $106.87 $95.62 73700 Ct lower extremity w/o dye 5570 $112.49 $106.87 $95.62 74150 Ct abdomen w/o dye 5570 $112.49 $106.87 $95.62 74261 Ct colonography dx 5570 $112.49 $106.87 $95.62 70460 Ct head/brain w/dye 5571 $236.86 $225.02 $201.33 70470 Ct head/brain w/o &
w/dye 5571 $236.86 $225.02 $201.33 70481 Ct orbit/ear/fossa w/dye 5571 $236.86 $225.02 $201.33 70482 Ct orbit/ear/fossa w/o&w/dye 5571 $236.86 $225.02 $201.33 70487 Ct maxillofacial w/dye 5571 $236.86 $225.02 $201.33 70488 Ct maxillofacial w/o & w/dye 5571 $236.86 $225.02 $201.33 70491 Ct soft tissue neck
w/dye
5571 $236.86 $225.02 $201.33 70492 Ct sft tsue nck w/o &
w/dye 5571 $236.86 $225.02 $201.33 70496 Ct angiography head 5571 $236.86 $225.02 $201.33 70498 Ct angiography neck 5571 $236.86 $225.02 $201.33 71260 Ct thorax w/dye 5571 $236.86 $225.02 $201.33 71275 Ct angiography chest 5571 $236.86 $225.02 $201.33 72127 Ct neck spine w/o &
w/dye
5571 $236.86 $225.02 $201.33 72129 Ct chest spine w/dye 5571 $236.86 $225.02 $201.33 72130 Ct chest spine w/o &
w/dye
5571 $236.86 $225.02 $201.33 72133 Ct lumbar spine w/o 5571 $236.86 $225.02 $201.33
& w/dye
72191 Ct angiograph pelv w/o&w/dye
5571 $236.86 $225.02 $201.33 72193 Ct pelvis w/dye 5571 $236.86 $225.02 $201.33 72194 Ct pelvis w/o &
w/dye
5571 $236.86 $225.02 $201.33 73202 Ct uppr extremity
w/o&w/dye
5571 $236.86 $225.02 $201.33 73206 Ct angio upr extrm
w/o&w/dye 5571 $236.86 $225.02 $201.33 73701 Ct lower extremity w/dye 5571 $236.86 $225.02 $201.33 73702 Ct lwr extremity w/o&w/dye 5571 $236.86 $225.02 $201.33 73706 Ct angio lwr extr w/o&w/dye 5571 $236.86 $225.02 $201.33 74160 Ct abdomen w/dye 5571 $236.86 $225.02 $201.33 74170 Ct abdomen w/o &
w/dye
5571 $236.86 $225.02 $201.33 74175 Ct angio abdom w/o
& w/dye 5571 $236.86 $225.02 $201.33 74262 Ct colonography dx w/dye 5571 $236.86 $225.02 $201.33 75572 Ct hrt w/3d image 5571 $236.86 $225.02 $201.33 75573 Ct hrt w/3d image congen 5571 $236.86 $225.02 $201.33 75574 Ct angio hrt w/3d image 5571 $236.86 $225.02 $201.33 71270 Ct thorax w/o &
w/dye
5572 $347.72 $330.33 $295.56 72126 Ct neck spine w/dye 5572 $347.72 $330.33 $295.56 72132 Ct lumbar spine w/dye 5572 $347.72 $330.33 $295.56 73201 Ct upper extremity w/dye 5572 $347.72 $330.33 $295.56 74174 Ct angio abd&pelv w/o&w/dye 5572 $347.72 $330.33 $295.56 74177 Ct abd & pelv
w/contrast
5572 $347.72 $330.33 $295.56 74178 Ct abd & pelv 1/>
regns
5572 $347.72 $330.33 $295.56 75571 Ct hrt w/o dye w/ca
test
5731 $12.70 $12.07 $10.80 74263 Ct colonography Not paid by Medicare when submitted on
screening outpatient claims (any outpatient bill type).
Hospital Outpatient Quality Reporting (OQR) Program
Regarding the Hospital Outpatient Quality Reporting (OQR) Program, CMS is moving forward with a number, but not all, of its proposals for the CY 2017, 2018 and 2019 payment
determinations and those that carry over to subsequent years. CMS has elected to move forward with the removal of the OP-15: Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache measure, effective Jan. 1, 2016 stating that the measure does not align with current clinical guidelines or practices.
CMS has additionally elected to change the deadline for withdrawing from the Hospital OQR Program from Nov. 1 to Aug. 31. In order to increase the total time for review, CMS has elected to shift the quarters on which payment determinations are based. CMS also proposed a new data submission period for measures submitted via the QualityNet Website, shifting the timeframe from July 1 through Nov. 1 to Jan. 1 through May 15. One of the reasons for this change was to bring the data submission period in line with those proposed by the ASCQR Program which would streamline hospital submissions, earlier public reporting and a reduced administrative burden associated with tracking multiple submission deadlines for measures. Similarly, in order to be consistent with the proposed ASCQR Program, CMS has elected to move forward with a proposal to change the deadline for submitting a reconsideration request from the first business day of the month of February of the affected payment year to the first business day on or after March 17 of the affected payment year. Two minor clerical clarifications were also finalized for CY 2016: the renaming of the extension and exception policy to extension and exemption and the amendment of 42 CFR 419.46(f)(1) and 42 CFR 419.46(e)(2) to replace the term “fiscal year” with the term “calendar year.” The reasoning behind both of these was the remedy of inadvertent error, rather than the proscription of specific policy.
In the CY 2016 OPPS Proposed Rule, CMS proposed two new measures, OP-33: External Beam Radiotherapy (EBRT) for Bone Metastases (NQF # 1822) (for CY 2018 and subsequent years) and OP-34: Emergency Department Transfer Communication (EDTC) (NQF # 0291). The first of these, OP-33, which is designed to assesses the percentage of patients with painful bone metastases and no history of previous radiation who receive EBRT with an acceptable dosing schedule, has been finalized beginning for services furnished on January 1, 2016. The second proposal for this measure, which would allow hospitals to submit an aggregate data file for this measure through a vendor, was not finalized. Also not finalized was the proposed OP-34: Emergency Department Transfer Communication (EDTC) (NQF # 0291) measure. It was meant to address concerns associated with care transitions when patients are transferred from
Emergency Departments to other facilities. The reasoning for this was the anticipation of a significant overlap with the Meaningful Use Stage 2 requirements that would divert attention and resources away from another CMS priority. CMS also took comments regarding electronic clinical quality measures (eCQMs) and whether or not, in future rulemaking, CMS would propose that hospitals have the option to voluntarily submit data for OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients electronically beginning with the CY 2019 payment determination. Many of the comments came out in support of this optional measure while others worried about the management of data elements and the potential for
duplicative penalties. CMS noted that a validation pilot is currently under way in the Hospital IQR Program and the results of that pilot are pending but that they will take into consideration lessons learned in the Hospital IQR Program before developing Hospital OQR Program policies. The ACR’s HOPPS Committee and staff will be reviewing these changes and drafting comments during the 60-day comment period.