2016 Medicare Update NMD Healthcare Consulting
Presenter Rudy Karin Director, Reimbursement Strategy NMD Healthcare Consulting 2
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) Background Repeal of SGR & impact on CF Policy Changes Procedure Reimbursement Q & A 3
NM & PET CODE CHANGES CY 2016 4
New & Revised CPT Codes CY 2016 CPT Code Long Descriptor 78264 78265 Gastric Emptying Imaging Study (eg, solid, liquid or both); 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
New HCPCS Level II Codes CY 2016 HCPCS Level II Code C9458 9458 APC Description SI Florbetaben F-18, diagnostic, per study dose, up to 8.1 millicuries (Trade Name: Neuraceq; Mfr d by Piramal; NDC# 54828-0001-30 (30 ml vial)) 1Q 2016 Rate FINAL (Proposed) G $2,968.00 C9459 9459 Flutemetamol F-18, diagnostic, per study dose, up to 5 millicuries (Trade Name: Vizamyl; Mfr d by G.E.; 17156-0067-10 (10 ml vial) or 17156-0067-30 (30 ml vial)) G $3,135.00 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
HOSPITAL OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (HOPPS) 2016 7
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
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 9
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 10
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
2016 HOPPS Policies Continued What did NOT change? Pass-Through Status (SI G ) for 1 Dx RP Continues: Amyvid, HCPCS A9606 (Eff 1/1/2015; continues 2 nd Yr.) Reimbursement remains at ASP+6% or WAC+6% Diagnostic Radiopharmaceuticals (w/o Pass-Through Status N ) 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) Composite APCs - Multiple Imaging remains unchanged Sequestration 2% Reduction Continues Coding Edits for RPs Not Reinstated 12
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. 31 st, 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
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 14
HOPPS NM APC Restructuring CY 2016 FINAL APC APC Descriptor FINAL Assignments SI 5591 5592 5593 5594 5661 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 1Q 2016 Rate FINAL S $332.65 S $441.36 S $1,108.46 S $1,285.17 S $249.98 15
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) 16
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
Nuclear Cardiology MPI APC & Rate Changes CPT Code Descriptor APC HOPPS Rate 2015 2016 4Q 2015 1Q 2016 % Change 78451 78452 78453 78454 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) 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 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) 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% 0377 5593 $1,140.54 $1,108.46-2.8% 0377 5592 $1,140.54 $441.36-61.3% 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% 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 18
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
Cardiovascular PET APC & Rate Changes CPT Code Descriptor APC HOPPS Rate 2015 2016 4Q 2015 1Q 2016 % Change 78459 78491 78492 Myocardial imaging, positron emission tomography (PET), metabolic evaluation 0308 5594 $1,286.23 $1,285.17-0.1% Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress 0308 5594 $1,286.23 $1,285.17-0.1% Myocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress 0308 5594 $1,286.23 $1,285.17-0.1% 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% 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
Cardiovascular System APC & Rate Changes CPT Code 0331T 0332T Descriptor 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% 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 78468 78469 Myocardial imaging, infarct avid, planar; qualitative or quantitative 0398 5591 $373.56 $332.65-11.0% Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique 0398 5591 $373.56 $332.65-11.0% 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
MUGA Studies APC & Rate Changes CPT Code Descriptor APC HOPPS Rate 2015 2016 4Q 2015 1Q 2016 % Change 78472 78473 78481 78483 78494 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 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 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 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 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% 0398 5591 $373.56 $332.65-11.0% 0398 5592 $373.56 $441.36 +18.1% 0377 5592 $1,140.54 $441.36-61.3% 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 ( N ) Pkg d ( N ) NA Note: Dx RPs & Pharmacologic Stress Agents Status Indicator N ; Packaged into APC Procedure Payment 22
Non Cardiac PET APC & Rate Changes CPT Code Descriptor APC 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 78815 78816 PET with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) PET with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to midthigh 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% 0308 5594 $1,286.23 $1,285.17-0.1% 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
Musculosketal Imaging APC & Rate Changes CPT Code Descriptor APC 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
Hematopoietic, Reticuloendothelial & Lymphatic System APC & Rate Changes CPT Code Descriptor APC 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 78185 Red cell survival study; differential organ/tissue kinetics (eg, splenic and/or hepatic sequestration) Spleen imaging only, with or without vascular flow 0393 5591 $628.19 $332.65-47.0% 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 0392 5591 Pkg d or$280.27 (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 25 Pkg d or$332.65 (Q1) +18.7%
Gastrointestinal System APC & Rate Changes CPT Code Descriptor APC 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 78227 Hepatobiliary system imaging, including gallbladder when present; 0394 5591 $373.05 $332.65-10.8% 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 78266 Gastric emptying study (eg, solid. Liquid, or both); with small bowel transit New 5591 New $336.75 NA 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
Respiratory System APC & Rate Changes CPT Code Descriptor APC 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 78597 78598 Pulmonary ventilation (eg, aerosol or gas) and perfusion imaging Quantitative differential pulmonary perfusion, including imaging when performed Quantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed 0378 5592 $440.34 $441.36 +0.2% 0401 5591 $315.89 $332.65 +5.3% 0378 5592 $440.34 $441.36 +0.2% Note: Dx RPs & Pharmacologic Stress Agents Status Indicator N ; Packaged into APC Procedure Payment 27
Genitourinary System APC & Rate Changes CPT Code Descriptor APC 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 78708 78709 Kidney imaging morphology; with vascular flow and function, single study without pharmacological intervention Kidney imaging morphology; with vascular flow and function, single study, with pharmacological intervention (eg, angiotensin converting enzyme inhibitor and/or diuretic) 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% 0404 5592 $420.66 $441.36 +4.9% 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% +78730 78740 Urinary bladder residual study (List separately in addition to code for primary procedure) NA NA Pkg d Pkg d NA 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
Other (Abscess, Tumor, etc.) APC & Rate Changes CPT Code Descriptor APC HOPPS Rate 2015 2016 4Q 2015 1Q 2016 % Change 78800 78801 78802 78803 78804 78805 78806 78807 78808 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area 0406 5591 $377.33 $332.65-11.8% Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); multiple areas 0406 5591 $377.33 $332.65-11.8% Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); whole body, single day imaging 0414 5592 $706.73 $441.36-37.5% Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); tomographic (SPECT) 0414 5592 $706.73 $441.36-37.5% 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% Radiopharmaceutical localization of inflammatory process; limited area 0414 5593 $706.73 $1,108.46 +56.8% Radiopharmaceutical localization of inflammatory process; whole body 0414 5593 $706.73 $1,108.46 +56.8% Radiopharmaceutical localization of inflammatory process; tomographic (SPECT) 0414 5592 $706.73 $441.36-37.5% Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (eg, parathyroid adenoma) 0392 5591 Pkg d or $280.27 (Q1) Pkg d or $332.65 (Q1) NA or +18.7% 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
Therapeutic APC & Rate Changes CPT Code Descriptor APC HOPPS Rate 2015 2016 4Q 2015 1Q 2016 % Change 79005 79101 79200 79300 79403 79440 79445 Radiopharmaceutical therapy, by oral administration 0407 5661 $276.93 $249.98-9.7% Radiopharmaceutical therapy, by intravenous administration 0407 5661 $276.93 $249.98-9.7% Radiopharmaceutical therapy, by intracavitary administration 0407 5661 $276.93 $249.98-9.7% Radiopharmaceutical therapy, by interstitial radioactive colloid administration 0407 5661 $276.93 $249.98-9.7% Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion 0407 5661 $276.93 $249.98-9.7% Radiopharmaceutical therapy, by intra-articular administration 0407 5661 $276.93 $249.98-9.7% 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
Therapeutic RPs APC & Rate Changes HCPCS Code A9517 A9530 A9543 A9563 A9564 A9600 A9604 A9606 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) APC HOPPS Rate 2015 2016 4Q 2015 1Q 2016 % Change 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 Coding Tips 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 1 st, 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. 32
MEDICARE PHYSICIAN FEE SCHEDULE (MPFS) 2016 33
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 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. 34
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
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 Geographic Practice Conversion Local Medicare Units (RVU) X Cost Index (GPCI) X Factor (CF) = Payment Rate 36
2016 PFS Changes Affecting NM Procedures: Sustainable Growth Rate (SGR) Formula 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 37
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
CY 2016 MPFS Policies (cont) 2% Sequestration Continues DRA Cap on the Technical and Global Allowables for imaging procedures Separate Payment for Radiopharmaceuticals 39
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: Based on Average Selling Price (ASP) + 6% Medicare publishes an ASP Pricing file with the payment rates quarterly 40
Multiple Procedure Payment Reductions (MPPR) NO NEW Multiple Procedure Payment Reductions in 2016! 41
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
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
Nuclear Medicine SPECT MPI MPFS Global National Rates (GL) CPT Code Status 78451 A 78452 A 78453 A 78454 A 93015 A Descriptor 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) 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 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) 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 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision, interpretation and report Notes: Dx Radiopharmaceutical, Stress Agents paid separately; CPT 93015 billed separately 4Q 2015 Rates 1Q 2016 Rates % Change $355.74 $355.89 +0.04% $492.65 $493.03 +0.08% $317.29 $317.23-0.02% $454.20 $456.15 +0.43% $77.26 $76.98-0.36% 44
Lymphoseek MPFS Global National Allowables CPT Code Status Descriptor 38792 A 78195 A 78195-26 A 78195-TC A Injection procedure; radioactive tracer for identification of sentinel node Lymphatics and lymph nodes imaging Lymphatics and lymph nodes imaging Lymphatics and lymph nodes imaging 4Q 2015 Rates 1Q 2016 Rates % Change $40.96 $41.17 +0.51% $371.19 $371.29 +0.03% $60.01 $60.15 +0.23% $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
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. AmyVid (A9586); Neuraceq & Vizamyl (A9599) 46
Links for more information 2016 FINAL Hospital Outpatient Prospective Payment System https://www.cms.gov/medicare/medicare-fee-for-service- Payment/HospitalOutpatientPPS/Hospital-Outpatient- Regulations-and-Notices-Items/CMS-1633- FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=desc ending 2016 FINAL Physician Fee Schedule (MPFS) https://www.cms.gov/medicare/medicare-fee-for-service- Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices- Items/CMS-1631- FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=desc ending 47
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
Thank you! 49
Q&A 50
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, 9 th Clinical Modification IDTF Independent Diagnostic Testing Facility LCD Local Coverage Determination 51
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