On October 30, 2008, the Centers for Medicare & Medicaid Services (CMS) posted a final rule for Medicare payment for hospital outpatient services and ambulatory surgical centers for calendar year (CY) 2009.  This final rule affects payments to hospitals and ambulatory surgical centers (ASC) for services paid under the Outpatient Prospective Payment  (HOPPS) and ASC Systems.  CMS included a 3.6 percent annual inflation update to Medicare payment rates for most services paid under the OPPS, however not all procedures important to the nuclear medicine community will see the full increase (see table below). Important final 2009 CMS HOPPS policy provisions include:

• Payments for ALL diagnostic radiopharmaceuticals and contrast agents continue to be packaged in with the APC category (major service procedure). CMS will continue to use hospital claims data median costs, as derived from hospital charges reduced by department specific Cost to Charge Ratios (CCR) for rate setting in 2009.
• The 2008 rate setting methodology for diagnostic nuclear medicine APCs is also extended for one more year in 2009, using only claims that include a charge with a required diagnostic, therapeutic or other radioactive product.
• CMS noted "they will use the device methodology to estimate radiopharmaceutical (RP) offset costs that could reasonably be attributed to the diagnostic RP packaged into APC groups" in an effort to avoid duplicate payments for (new) transitional pass-through diagnostic RP payments.
• For 2009, CMS stated "there are currently no radiopharmaceuticals with pass-through status, nor do we have any pass-through applications for radiopharmaceuticals under review at the time of this final rule".
• CMS did create a new HCPCS Level II code C9247 to report AdreView™ and/or I-123 MIBG see Table 2, however, CMS packaged this diagnostic radiopharmaceutical payment with the procedure payment rate in 2009.
• The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) enacted on July 15, 2008 mandated CMS' continuation of rate setting for therapeutic radiopharmaceuticals and brachytherapy sources using the individual (overall) hospital Cost to Charge Ratio (CCR) multiplied times the individual hospital charges through December 31, 2009. CMS was pleased that nuclear medicine stakeholders were interested in an ASP methodology for therapeutic radiopharmaceuticals, but noted that the law was clear and left no opportunity for changes in 2009.
• Drugs and biologicals are to be paid at 104 percent of the average sales price (ASP+4).  Please note, that in the physician office and Independent Diagnostic Testing Facility (IDTF) settings the current rate is set at 106 percent of average sales price (ASP).
• Drugs, biologicals and therapeutic radiopharmaceuticals costing $60 or more per day will be reimbursed separately.  Drugs costing less than $60 per day will be bundled into payments for their associated procedures. One important change to note:
• J2805 – Injection sincalide, 5 mcg (packaged drug in 2008), will be paid separately with status indicator K at a rate of $60.01. This drug reverted back to being paid separately for 2009 due to CMS' claims methodology for calculating drug costs.
• Add-on "image processing services" continue to be packaged for 2009 in with the costs of the major procedures including CPT codes: 76376, 76377, 78020, 78478, 78480 and 78496.