(1) CMS ANNOUNCES PROPOSED CHANGES FOR HOSPITAL OUTPATIENT SERVICES (HOPPS) Effective January 1, 2008
On July 16, 2007, the Centers for Medicare & Medicaid Services (CMS) posted a proposed rule for Medicare payment for hospital outpatient services in calendar year (CY) 2008. The proposed rules affect hospital outpatient and ASC payments for services paid under the outpatient prospective payment (HOPPS) and ASC systems. Important Nuclear Medicine, Nuclear Cardiology and Cardiac CTA proposed CMS policies include:- CMS proposes bundling payments for ALL diagnostic radiopharmaceuticals and contrast agents in with the APC category (major service procedure).
- Therapeutic Radiopharmaceuticals are proposed to be paid by CMS setting a prospective payment rate using the CMS claims mean data at charges adjusted using department-specific cost-to-charge ratio.
- Drugs and biologicals proposed to be paid at 105 percent of the average sales price (ASP+5), versus the current rate of 106 percent of average sales price (ASP).
- CMS proposes to pay separately for drugs, biologicals and therapeutic radiopharmaceuticals costing $60 or more per day. Payments for other drugs with some exceptions will remain bundled into their associated procedure payments.
- CMS proposes bundling many add-on "image processing services" with the costs of the major procedure CPT codes. Examples of bundled CPTs are, 76376, 76377, 78020, 78478, 78480, 78496, and 93325.
- CMS has reconfigured several of the CPT codes within APC categories such as multiple and single study procedure codes keeping some single vs multiple study CPT codes separate while collapsing others. 78465 will remain in its own APC 0377; 78461 will be collapsed into APC 0398; and Cardiac PET single and multiple studies combined into APC 0307. Nuclear medicine technologies such as PET and PET/CT collapsed into APC 0308.
The final rule is now posted on the CMS website at: http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage
It was placed on display at the Federal Register on July 16, 2007, and will be published August 2, 2007. It would be effective for outpatient and ASC services furnished to Medicare beneficiaries on or after January 1, 2008.
CMS encourages all to submit comments on this proposed notice by September 14, 2007, electronic submission at URL: http://www.cms.hhs.gov/eRulemaking/ Docket ID CMS-1392-
(2) CMS ANNOUNCES PROPOSED MEDICARE PHYSICIAN FEE (MPFS) SCHEDULE PAYMENT RATES & POLICIES Effective January 1, 2008
On July 2, 2007, the Centers for Medicare & Medicaid Services (CMS) posted a proposed notice for Medicare payments in the physician fee schedule for calendar year (CY) 2008. CMS will publish this information in the July 12, 2007 federal register.
The proposed rule affects physicians and office payment for services paid under the resource based relative value scale (RBRVS), also known as, the Medicare Physician Fee Schedule ([MPFS] billed on the 1500 claim forms.) Important Nuclear Medicine and Nuclear Cardiology proposed CMS policiy highlights include:- The Conversion Factor (CF) for 2008 would be set at $34.1457 if congress does not intervene resulting a -9.9% reduction from the 2007 frozen CF.
- CMS adopts recommendations of the American Medical Association (AMA) RUC committee for more codes deferred from the Five Year Review (FYR) as well as increases the value of the work component of anesthesia services by 32%. Therefore, similar to last years final rule CMS proposes to implement a budget neutrality (BN) adjustor (0.8816), which is applied to the work relative value units (RVUs) for all CPT codes resulting in a negative adjustment (-11.8% to all CPT code work RVUs) in the formula to make the overall payments in this system budget neutral. So be careful in your calculations of the proposed payment rates for 2008.
- The proposed rule continues its second year, with a 50% phase in of a new methodology for determining practice expense (PE) (such as office overhead) RVUs, with the phase in over a total of four years. For 2008, CMS will apply 50%, in 2009 75% and full implementation in 2010.
- There are NO proposed changes for radiopharmaceutical payment methodology in the physician office or IDTF setting for 2008.
- Drugs, contrast agents and biologicals will continue to be paid at 106 percent of the average sales price (ASP+6). However, CMS is proposing to again revise the methodology for determining the average sales price (ASP) for Part B drugs by defining bundled arrangements and requiring that drug manufacturers allocate bundled arrangements when reporting ASPs.
- Consistent with requirements of the DRA, this proposed rule caps payment rates for imaging services under the physician fee schedule at the amount paid for the same services when performed in hospital outpatient departments. The HOPPS rule posted on July 16, 2007, proposes bundling of many add-on CPT codes and diagnostic radiopharmaceutical codes as well as contrast agents. It is currently unclear how Medicare contractors will implement these bundling changes with the DRA provision. The "potential good news" is that this bundling appears to have reduced the number of nuclear medicine and nuclear cardiology codes affected by the DRA CAP.
- As directed by the Tax Reform and Health Care Act of 2006 (TRHCA), CMS outlines measures from seven categories for inclusion in the 2008 Physician Quality Reporting Initiative (PQRI). There are currently NO nuclear medicine measures. However, if your physicians see patients for evaluation and management services in addition to their imaging practices, they may be able to use other measures, such as cardiology or endocrinology to benefit from the 1.5% bonus on all their nuclear medicine or nuclear cardiology procedures, including radiopharmaceuticals, but not drugs.
- CMS is modifying a number of the physician self-referral provisions to close loopholes that have made the Medicare program vulnerable to abuse. The new proposal adds an antimark-up restriction on interpretation services and eliminates the requirement for on-site reading.
The proposed rule is now posted on the CMS website at: http://www.cms.hhs.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
The proposed rule went on display at the Federal Register July 2, 2007, and will be published on July 12, 2007. The information from this proposed notice would be effective for services on or after January 1, 2008.
CMS encourages all to submit comments on this proposed notice by August 31, 2007, electronic submission at URL: http://www.cms.hhs.gov/eRulemaking/ Docket ID CMS-1385-P
