Presented by Barbara Ossias
Sponsored by UPPI
 Overview
of the 2012 Changes with
Medicare
• HOPPS
• MPFS including SGR Update
 Coding
Changes
 Healthcare Reform in 2012
Q & A
 The
HOPPS payment rates increased by 1.9%
on January 1st
 CMS estimates that payments will total $41.1
billion for 4,000 hospitals, including general
acute care hospitals, inpatient rehabilitation
facilities, inpatient psychiatric facilities, longterm acute care hospitals, children's hospitals,
and cancer hospitals
• Cancer hospitals specifically will see increased
payments of 11.3% (approximately $71 million)


2012 will see continued packaging of payment for
services and agents in seven categories into the
reimbursement for the primary diagnostic or
therapeutic procedure; these are services and agents
that CMS has deemed ancillary to the primary
procedure
The seven categories are:
• Guidance services
• Image processing services
• Intraoperative services
• Imaging supervision and interpretation services
• Diagnostic radiopharmaceuticals
• Contrast media
•
Observation services
 Despite
comments on the unique nature of
radiopharmaceuticals and issues like special
handling and disposal requesting acquisition
and pharmacy overhead costs, including
compounding costs CMS held firm in not
making separate reimbursement for these
agents


The HOPPS Final Rule established that CMS will
continue to update payment rates on products having
been granted pass-through status on a quarterly basis
on the CMS Web site during CY 2012 and reiterated
that CMS considers radiopharmaceuticals to be drugs
under HOPPS
Per the Final Rule, any diagnostic or therapeutic
radiopharmaceutical that receives pass-through status
during CY 2012 will be reimbursed at the standard ASP
methodology as basis of pass-through payment rate



In 2012 CMS continued the assignment of PET
myocardial procedures to APC 0307 (Myocardial
Position Emission Tomography (PET) Imaging) with a
national unadjusted rate of $921 in the Final Rule
This is a significant decrease from the 2011 national
unadjusted rate of $1,107
Given that all diagnostic radiopharmaceuticals are
packaged into the APC for the related procedure, this
decrease might have a negative impact on the facilities
offering these procedures


After reviewing additional comments that came in on
the Final Rule CMS changed the APC assignment for
cardiac PET to APC 308
In adding cardiac PET into APC 0308 CMS revised the
national unadjusted rate to be $1,036.95


Other CPT codes for brain imaging, tumor imaging,
positron emission tomography (PET) imaging and
PET/CT have been assigned to APC 0308 (NonMyocardial Positron Emission Tomography (PET)
imaging) in 2012 with a national unadjusted rate of
$1,015
This rate is down from the 2011 national unadjusted
rate for APC 0308 is $1,042 and again, this decrease
might have negative ramifications for facilities
providing these procedures


The 2012 HOPPS Final Rule reassigns CPT code 77338
(Multi-leaf collimator (MLC) device(s) for intensity
modulated radiation therapy (IMRT), design and
construction per IMRT plan) from APC 0310 to APC
0305
This reassignment to APC 0305 (with a national
unadjusted rate of $256.92) from APC 0310 (with a 2011
national unadjusted rate of $919.54) represents a
decrease of approximately 72% for the code in 2012


The reduction is made more severe by the fact in 2010
CPT code 77334 (treatment devices, design and
construction; complex [irregular blocks, special
shields, compensators, wedges, molds or casts]) was
replaced by code 77338
Prior to 2010, facilities could report an unlimited
number of units for code 77334 and be paid for each
device used in a treatment, but 77338 cannot be
reported in multiple units, only a single unit of service

The Final Rule revised the physician supervision rules
that apply to hospital outpatient services. The changes
now include the following:
• The federal Advisory Panel on Ambulatory Payment Classification
Groups (Panel) will serve as the independent review body that
evaluates individual hospital outpatient therapeutic services and
recommends to CMS a supervision level (general, direct or personal)
to ensure an appropriate level of quality and safety
• CMS will issue decisions based on Panel recommendations through
sub-regulatory guidance
• Definitions for personal supervision and general supervision for all
hospital outpatient therapeutic services will be added [to the rules]
 The
2012 Medicare Physician Fee Schedule
Final (MPFS) Rule where the biggest news by
far was the 27.4% cut in reimbursement
mandated by the Sustainable Growth Rate
(SGR) formula
• This cut is less than the 29.5% reduction put forth in the
2012 Proposed Rule for the MPFS, but still a major blow to
providers in the Part B setting
 In
total, CMS projects total payments under the
MPFS in calendar year 2012 will be
approximately $80 billion
 The
SGR is the annual growth rate formulary
used to establish physician reimbursement
under Medicare and there have been 11 times
that the SGR has called for a cut since the
formula first came into existence – the majority
of which have been repealed by legislative
action after the release of a Final MPFS Rule
 President
Obama signed legislation in
February averting 27.4% reduction
 The reprieve is postpones any fee schedule
reduction until January 1st 2013
 We will continue to monitor the situation and its
potential impact on practice revenues
 In
2012 CMS continues paying for all multiple
imaging procedures within an imaging family
performed on the same date of service using
the multiple imaging composite payment
methodology
 The multiple imaging procedure families do
not include nuclear medicine, but do impact CT
and MR procedures
 In
another area related to multiple imaging
procedures, CMS implemented a three-day
policy window payment provisions
 This will pay physicians services at the lower
facility rate if they are delivered in a physician
office wholly owned and operated by a hospital
and provided within three days of a hospital
admission
 Meaningful
use of electronic health records by
eligible professionals within the Medicare and
Medicaid EHR Incentive Programs will continue
per the 2012 Final MPFS Rule
 For 2012 CMS finalized several requirements
related to how groups and individual
physicians report to the PQRI
 A total of 23 measures for reporting include
several new groups, such as cardiovascular
prevention, dementia, Parkinson's, cataracts
and others
 Just
because there is a code doesn’t
mean it will be reimbursed
 Variables of reimbursement
• Coverage
• Edits
• Deductibles and co-pays
• Prior authorization requirements
 77470
- Special treatment procedure
(e.g., total body irradiation, hemibody
radiation, per oral or endocavitary
irradiation)
 78580 - Pulmonary perfusion imaging
(e.g., particulate)
 Hepatobiliary
imaging code 78223 has been
deleted and replaced by two new codes
• 78226--Hepatobiliary system imaging, including
gallbladder when present
• 78227--Hepatobiliary system imaging, including
gallbladder when present; with pharmacologic
intervention, including quantitative measurement(s) when
performed
 Nine
existing lung imaging codes, 7858478596, have been combined into four new
codes
• 78579--Pulmonary ventilation imaging (e.g., aerosol or
gas)
• 78582--Pulmonary ventilation (e.g., aerosol or gas) and
perfusion imaging
• 78597--Quantitative differential pulmonary perfusion,
including imaging when performed
• 78598--Quantitative differential pulmonary perfusion and
ventilation (e.g., aerosol or gas), including imaging when
performed
 A9584
Iodine I-123 Ioflupane, diagnostic, per
study dose, (up to 5 millicuries) - for DaTscan®
used for striatal dopamine transporter
visualization using single photon emission
computed tomography (SPECT) brain imaging
 Please
call UPPI Reimbursement Support
(888 900 2674) for a complete listing of
the HCPCS codes used in nuclear
medicine
 ICD.9-CM

code 793.1 was used to report PET scan
performed prior to biopsy for diagnosis of lung cancer
in patients with lung masses, solitary pulmonary
nodules and multiple pulmonary nodules
In 2012 this code was deleted with the addition of two
new five digit codes as follows:
• 793.11 - Solitary pulmonary nodule
• 793.19 - Other nonspecific abnormal findings of lung field
 The
2012 Final Rule for the MPFS implements
parts of the Patient Protection and Affordable
Care Act (Healthcare Reform as we lovingly
refer to it) including Section 3007 which
requires CMS to apply a value modifier
comparing the quality of care delivered to the
cost of that care, to physician payment rates
 All physicians and physician groups under the
MPFS will be held to the value modifier by 2017
 The
items relating to the value modifier include
quality of care measures (e.g., cardiovascular
and chronic conditions and preventive
measures) and cost measures (e.g., total per
capita cost and per capita cost for conditions
such as chronic obstructive pulmonary disease,
heart failure, diabetes and others)
 The
law establishes a hospital Value Based
Purchasing Program (VBP) offering financial
incentives to hospitals to improve the quality of
care
 Hospital performance is required to be
publicly reported, beginning with measures
relating to heart attacks, heart failure,
pneumonia, surgical care, health-care
associated infections, and patients’ perception
of care
• Effective for payments for discharges occurring on or after
October 1, 2012
 The
new law provides incentives for physicians
to join together to form “Accountable Care
Organizations”
 These groups allow doctors to better
coordinate patient care and improve the
quality, help prevent disease and illness and
reduce unnecessary hospital admissions
 ACOs that provide high quality care and
reduce costs to the health care system, they can
keep some of the money that they have helped
save
• Effective January 1, 2012
 Health
care remains one of the few industries
that relies on paper records and healthcare
reform institutes a series of changes to
standardize billing and requires health plans to
adopt electronic exchange of health
information
 Electronic Health Records (EHR) will reduce
paperwork and administrative burdens, cut
costs, reduce medical errors and most
importantly, improve the quality of care
• First regulation effective October 1, 2012
Q&A
Barbara Ossias
Reimbursement Revenue Solutions
Direct line 301 371 4829
Reimbursement Hotline 1 888 900 2674
bossias@reimbursementrevenuesolutions.co
m
www.reimbursementrevenuesolutions.com