2016 Medicare Update
NMD Healthcare Consulting
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Presenter
Rudy Karin
Director, Reimbursement Strategy
NMD Healthcare Consulting
2
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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)
–
–
–
–
•
3
Background
Repeal of SGR & impact on CF
Policy Changes
Procedure Reimbursement
Q&A
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NM & PET CODE CHANGES
CY 2016
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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
(Report 78264, 78265, or 78266 only once per imaging study)
5
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New HCPCS Level II Codes CY 2016
HCPCS
Level II
Code
C9458
APC
Description
SI
1Q 2016 Rate
FINAL
(Proposed)
G
$2,968.00
G
$3,135.00
Florbetaben F-18, diagnostic, per study
dose, up to 8.1 millicuries
9458
(Trade Name: Neuraceq; Mfr’d by Piramal;
NDC# 54828-0001-30 (30 ml vial))
Flutemetamol F-18, diagnostic, per study
dose, up to 5 millicuries
C9459
9459
(Trade Name: Vizamyl; Mfr’d by G.E.; 171560067-10 (10 ml vial) or 17156-0067-30 (30 ml
vial))
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)
6
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HOSPITAL OUTPATIENT
PROSPECTIVE PAYMENT
SYSTEM (HOPPS) – 2016
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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
8
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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
fluctuation
CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered
trademark of the American Medical Association
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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
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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
• Dx RP edit ended; but you still need to put it on the claim
11
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2016 HOPPS – Policies Continued
What did NOT change?
•
Pass-Through Status (SI “G”) for 1 Dx RP Continues:
–
–
•
Diagnostic Radiopharmaceuticals (w/o Pass-Through Status “N”)
–
–
•
•
Amyvid, HCPCS A9606 (Eff 1/1/2015; continues 2nd Yr.)
Reimbursement remains at ASP+6% or WAC+6%
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)
•
•
•
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Composite APCs - Multiple Imaging remains unchanged
Sequestration 2% Reduction Continues
Coding Edits for RPs – Not Reinstated
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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. 31st, 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
13
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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
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HOPPS NM APC Restructuring – CY 2016 FINAL
APC
5591
5592
5593
5594
5661
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APC Descriptor – FINAL Assignments
Level 1 Nuclear Medicine & Related
Services
Level 2 Nuclear Medicine & Related
Services
Level 3 Nuclear Medicine & Related
Services
Level 4 Nuclear Medicine & Related
Services
Therapeutic (Non-Imaging) Nuclear
Medicine
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SI
1Q 2016 Rate
FINAL
S
$332.65
S
$441.36
S
$1,108.46
S
$1,285.17
S
$249.98
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)
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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
17
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Nuclear Cardiology MPI – APC & Rate Changes
CPT
Code
APC
HOPPS Rate
2015
2016
4Q 2015
1Q 2016
%
Change
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%
Descriptor
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
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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
Total
$856.50
$856.50
$1070.22
$1075.26
$1153.62
$1,140.54
$1,108.46
19
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Cardiovascular PET – APC & Rate Changes
CPT
Code
APC
HOPPS Rate
Descriptor
2015
2016
4Q 2015
1Q 2016
%
Change
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%
5722
Pkg’d or
$238.04
(Q1)
Pkg’d or
$220.35
(Q1)
-7.4%
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
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
20
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Cardiovascular System – APC & Rate Changes
CPT
Code
Descriptor
0331T
APC
HOPPS Rate
%
Change
2015
2016
4Q 2015
1Q 2016
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%
78468
Myocardial imaging, infarct avid, planar; with
ejection fraction by first pass technique
0398
5591
$373.56
$332.65
-11.0%
78469
Myocardial imaging, infarct avid, planar;
tomographic SPECT with or without quantification
0398
5592
$373.56
$441.36
+18.1%
Note: Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment
21
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MUGA Studies – APC & Rate Changes
APC
CPT
Code
Descriptor
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
Pkg’d
(“N”)
(“N”)
Note: Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure
Payment
22
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NA
Non Cardiac PET – APC & Rate Changes
CPT
Code
APC
Descriptor
HOPPS Rate
2015
2016
4Q 2015
1Q 2016
%
Change
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 midthigh
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
0308
5594
$1,286.23
$1,285.17
-0.1%
Note: Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment
23
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Musculosketal Imaging – APC & Rate Changes
CPT
Code
APC
Descriptor
HOPPS Rate
2015
2016
4Q 2015
1Q 2016
%
Change
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
24
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Hematopoietic, Reticuloendothelial & Lymphatic
System – APC & Rate Changes
CPT
Code
APC
Descriptor
HOPPS Rate
2015
2016
4Q 2015
1Q 2016
%
Change
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 volumedilution 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%
78195
Lymphatics and lymph nodes imaging
0400
5591
$369.60
$332.65
-10.0%
38792
Injection procedure; radioactive tracer for
identification of sentinel node
5591
Pkg’d
or$280.27
(Q1)
Pkg’d
or$332.65
(Q1)
+18.7%
0392
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
25
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Gastrointestinal System – APC & Rate Changes
CPT
Code
APC
Descriptor
HOPPS Rate
2015
2016
4Q 2015
1Q 2016
%
Change
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
26
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Respiratory System – APC & Rate Changes
CPT
Code
APC
Descriptor
HOPPS Rate
2015
2016
4Q 2015
1Q 2016
%
Change
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%
Note: Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment
27
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Genitourinary System – APC & Rate Changes
APC
CPT
Code
Descriptor
HOPPS Rate
2015
2016
4Q 2015
1Q 2016
%
Change
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%
NA
NA
Pkg’d
Pkg’d
NA
+78730
Urinary bladder residual study (List separately in
addition to code for primary procedure)
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
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Other (Abscess, Tumor, etc.)
APC & Rate Changes
APC
CPT
Code
Descriptor
78800
HOPPS Rate
%
Change
2015
2016
4Q 2015
1Q 2016
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%
78807
Radiopharmaceutical localization of inflammatory
process; tomographic (SPECT)
0414
5592
$706.73
$441.36
-37.5%
78808
Injection procedure for radiopharmaceutical localization
by non-imaging probe study, intravenous (eg, parathyroid
adenoma)
0392
5591
Pkg’d or
Pkg’d or
$280.27 (Q1) $332.65 (Q1)
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
29
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NA or
+18.7%
Therapeutic – APC & Rate Changes
CPT
Code
APC
Descriptor
HOPPS Rate
2015
2016
4Q 2015
1Q 2016
%
Change
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
30
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Therapeutic RPs – APC & Rate Changes
HCPCS
Code
A9517
A9530
A9543
A9563
A9564
A9600
A9604
A9606
APC
Descriptor
Iodine I-131 sodium iodide capsule(s),
therapeutic, per millicurie
Iodine I-131 sodium iodide solution,
therapeutic, per millicurie
Yttrium Y-90 ibritumomab tiuxetan,
therapeutic, per treatment dose, up to 40
millicuries (Trade Name – Zevalin)
Sodium phosphate P-32, therapeutic, per
millicurie
Chromic phosphate P-32 suspension,
therapeutic, per millicurie
Strontium Sr-89 chloride, therapeutic, per
millicurie (Trade Name – Metastron)
Samarium Sm-153 lexidronam,
therapeutic, per treatment dose, up to 150
millicuries (Trade Name – Quadramet)
Radium Ra-223 dichloride, therapeutic,
per microcurie (Trade Name – Xofigo)
%
Change
2015
2016
4Q 2015
1Q 2016
1064
1064
$40.70
$40.70
0.0%
1150
1150
$10.28
$10.28
0.0%
1643
1643
$46,304.42
$46,176.12
-0.3%
1675
1675
$213.56
$213.56
0.0%
1676
1676
$906.62
$906.62
0.0%
0701
0701
$1,160.34
$1,159.92
-0.04%
1295
1295
$10,962.42
$11,006.42
+0.4%
1745
1745
$112.30
$118.75
+5.7%
Note: Tx RPs paid separately; Status Indicator = “K”
31
HOPPS Rate
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HOPPS Coding Tips
•
•
•
•
•
•
•
•
•
32
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 1st, 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.
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MEDICARE PHYSICIAN FEE
SCHEDULE (MPFS)
2016
33
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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
•
•
•
•
•
•
34
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.
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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
– Global – Technical plus professional component combined
35
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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
Units (RVU)
X
36
Geographic Practice
Cost Index (GPCI) X
Conversion
Factor (CF)
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=
Local Medicare
Payment Rate
2016 PFS Changes Affecting NM Procedures:
Sustainable Growth Rate (SGR) Formula
37
•
•
•
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
* Statutory requirements require an act of Congress to change
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Conversion Factor & SGR Fix
Conversion Factor for 2015 & 2016:
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%
Mandated by the “Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
38
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CY 2016 MPFS Policies (cont)
• 2% Sequestration Continues
• DRA Cap on the Technical and Global
Allowables for imaging procedures
• Separate Payment for Radiopharmaceuticals
39
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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:
•
•
40
Based on Average Selling Price (ASP) + 6%
Medicare publishes an ASP Pricing file with the payment
rates quarterly
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Multiple Procedure Payment Reductions
(MPPR)
NO NEW
Multiple Procedure Payment Reductions
in 2016!
41
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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
42
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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
– SNMMI will conduct a survey to present to the April 2016 RUC Meeting.
43
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Nuclear Medicine – SPECT MPI
MPFS Global National Rates (GL)
CPT
Code
78451
78452
78453
78454
93015
4Q 2015
Rates
1Q 2016
Rates
%
Change
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%
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%
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%
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%
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%
Status
Descriptor
Notes: Dx Radiopharmaceutical, Stress Agents paid separately; CPT 93015 billed separately
44
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Lymphoseek® MPFS Global National
Allowables
CPT Code
Status
Descriptor
4Q 2015
Rates
1Q 2016
Rates
%
Change
$40.96
$41.17
+0.51%
38792
A
Injection procedure; radioactive
tracer for identification of sentinel
node
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)
45
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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.
–
46
AmyVid (A9586); Neuraceq & Vizamyl (A9599)
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Links for more information
2016 FINAL Hospital Outpatient Prospective Payment System
https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/Hospital-OutpatientRegulations-and-Notices-Items/CMS-1633FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=desc
ending
2016 FINAL Physician Fee Schedule (MPFS)
https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFS-Federal-Regulation-NoticesItems/CMS-1631FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=desc
ending
47
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Disclaimer
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.
48
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Thank you!
49
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Q&A
50
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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)
ICD-9-CM – International Classification of Diseases, 9th Clinical Modification
IDTF – Independent Diagnostic Testing Facility
LCD – Local Coverage Determination
51
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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
52
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