CMS Proposes 2018 Payment Rules for Outpatient Hospital Procedures and Physicians

July 17, 2017

On Thursday July 13, 2017 the Centers for Medicare and Medicaid Services (CMS) released both the proposed rules for Calendar Year (CY) 2018, the Hospital Outpatient Prospective Payment System (OPPS) and the Medicare Physician Fee Schedule (MPFS). Both rules have a 60-day public comment period. SNMMI has prepared payment rate charts for both rules (see below) and will submit comments by the end of the comment period. CMS will accept comments on the proposed rules until September 11, 2017. To provide comments on either rule go to OPPS or MPFS.

Compared to previous years they are relatively short at 815 pages and 688 pages respectively. This is probably due to a new administration gearing up and to CMS’s decision to separate the physician fee schedule and the quality measures into two separate rule (and our Quality Division is handling that Quality Payment Program Proposed Rule).

Hospital Outpatient Prospective Payment System CMS proposes to update OPPS rates by 1.75 percent for 2018. The change is based on the projected hospital market basket increase of 2.9 percent minus both a 0.4 percentage point adjustment for multi-factor productivity and a 0.75 percentage point adjustment required by law. After considering all other policy changes proposed under the OPPS (except for the 340B drug payment proposal), including estimated spending for pass-through payments, CMS estimates an overall impact of 2.0 percent payment increase for hospitals paid under the OPPS in CY 2018.

CMS proposes to move a few nuclear medicine CPT services into new APC groups based on hospital cost data from 2016 claims paid. Those CPT codes are 78018, 78110, 78111 and 78121. As noted in the payment table below, nuclear medicine payment, in general, is proposed to remain stable with modest increases proposed.

As mandated by statue, CMS proposes to package one diagnostic radiopharmaceutical that is on pass-through in 2017, A9586 Florbetapir f18, diagnostic, per study dose, up to 10 millicuries. A9586 is one of the three (3) Amyloid agents used in the IDEAS study. Absent legislation, we would not expect to see separate payment (from the procedure payment rate) for this agent in CY 2018.

 

APC

CMS Group Title

SI

July 2017 OPPS Rate

Proposed CY 2018 OPPS Rate

Percent Difference

5591

Level 1 Nuclear Medicine & Related Services

S

$333.08

$337.26

1.3%

5592

Level 2 Nuclear Medicine & Related Services

S

$429.13

$439.56

2.4%

5593

Level 3 Nuclear Medicine & Related Services

S

$1,138.94

$1,163.30

2.1%

5594

Level 4 Nuclear Medicine & Related Services

S

$1,321.53

$1,329.70

0.6%

5661

Therapy Nuclear Medicine

S

$216.68

$230.41

6.3%

 

View the July 2017 OPPS rates by Nuclear Medicine CPT code compared to the Proposed CY 2018 Hospital Rate SNMMI APC Chart.

The CMS fact sheet on the OPPS Proposed Rule can be accessed here. The American Hospital Association’s initial assessment of the hospital outpatient rule is at: http://news.aha.org/article/170714-cms-releases-2018-outpatient-pps-and-physician-payment-proposed-rules.

 Medicare Physician Fee Schedule

The update to payments under the MPFS based on the proposed CY 2018 rates would be +0.31 percent. This update reflects the statutory +0.50 percent update, reduced by 0.19 percent because net reductions in misvalued codes in 2018 are less than the statutorily set 0.50 percent target of total fee schedule revenue. After applying these adjustments, the proposed 2018 PFS conversion factor is $35.99, an increase to the 2017 PFS conversion factor of $35.89. The overall proposed CY 2018 PFS estimated impact on total allowed charges by specialty are as follows: Nuclear Medicine: (0%); Radiology (-1%); and Cardiology (-2%). However, we recommend you review the specific services you provide to determine your individual proposed impact, considering the volume and differing types of services you provide.

In past MPFS rules, CMS had identified three nuclear medicine CPT services; 78300, 78305 and 78306 Bone and/or joint imaging as potentially misvalued. The SNMMI along with ACR surveyed these codes and presented to the RUC, the RUC in turn made recommendations to CMS to maintain the current work values. CMS proposes to accept the RUC recommendation to maintain the work relative values in CY 2018. We greatly appreciate our SNMMI members for completing the AMA RUC surveys, without your input we are not able to support appropriate payment for our members.

Appropriate Use Criteria for Advanced Diagnostic Imaging – CMS Delays until 2019

CMS is proposing to implement the Medicare Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging in a manner that allows practitioners more time to focus on and adjust to the Quality Payment Program (p. 425). The Medicare AUC program is proposed to begin with an educational and operations testing year in 2019, which means physicians would be required to start using AUCs and reporting this information on their claims. During this first year, CMS is proposing to pay claims for advanced diagnostic imaging services regardless of whether they contain information on the required AUC consultation. This allows both clinicians and the agency to prepare for this new program.

In conjunction with the proposed rule, CMS is posting newly qualified provider-led entities and clinical decision support mechanisms. Qualified provider-led entities are permitted to develop AUC, and qualified clinical decision support mechanisms are the tools through which physicians use to access the AUC. Physicians may begin exploring these mechanisms well in advance of the start of the Medicare AUC program. In addition, by having qualified clinical decision support mechanisms available (some of which are free of charge) clinicians may use one of these mechanisms to earn credit under the Merit-Based Incentive Payment System as an improvement activity. This improvement activity was included in the Quality Payment Program proposed rule that was released on June 20, 2017.

It is important to receive comments that help CMS understand the current readiness of stakeholders. Therefore, CMS is specifically seeking comments related to whether the program should be delayed beyond the proposed start date of January 1, 2019, and are interested in comments regarding how long, if longer that one year, such a period of educational and operations testing should be available. 

Payment Rates for Off-campus Provider-Based Hospital Departments

Section 603 of the Bipartisan Budget Act of 2015 requires that items and services furnished in off campus provider-based departments will not be covered by OPPS payment beginning Jan. 1, 2017.  Most longstanding facilities were exempted from this rule. For CY 2017, CMS finalized the MPFS as the applicable payment system for most of these items and services. However, as a mechanism to pay they used the OPPS rate reduced by 50 percent as the method of payment. CMS proposes to change the MPFS payment rates for these services from 50 percent of the OPPS payment rate to 25 percent of the OPPS rate, this is CMS using incomplete data for setting rates in the off-campus non-exempted provider based office setting.

Request for Information – Better Transparency, Flexibility, Program Simplification and Innovation

In addition to the payment and policy proposals, CMS is releasing a Request for Information (RFI) to welcome feedback on positive solutions to better achieve transparency, flexibility, program simplification, and innovation. This will inform the discussion on future regulatory action related to the PFS.

CMS would like to start a national conversation about improving the healthcare delivery system; how Medicare can contribute to making the delivery system less bureaucratic and complex; and how we can reduce burden for clinicians, providers, and patients in a way that increases quality of care and decreases costs, thereby making the healthcare system more effective, simple, and accessible while maintaining program integrity and preventing fraud.

CMS is soliciting ideas for regulatory, sub-regulatory, policy, practice, and procedural changes to better accomplish these goals. Ideas could include recommendations regarding payment system re-design; elimination or streamlining of reporting; monitoring and documentation requirements; operational flexibility; and feedback mechanisms and data sharing that would enhance patient care, support the doctor-patient relationship in care delivery, and facilitate patient-centered care. Ideas could also include recommendations regarding when and how CMS issues regulations and policies and how CMS can simplify rules and policies for beneficiaries, clinicians, providers, and suppliers.

In responding to the RFI, CMS should be provided with clear and concise proposals that include data and specific examples. If the proposals involve novel legal questions, analysis regarding CMS’ authority is welcome. CMS will not respond to RFI comment submissions in the final rule, but rather will actively consider all input in developing future regulatory proposals or future sub-regulatory guidance. 

View the SNMMI 2018 PROPOSED rates compared to July 2017 rates for nuclear medicine services at Medicare Physician Fee Schedule Chart

CMS fact sheet on the MPFS Proposed Rule can be accessed here.