Proposed changes to MPFS and HOPPS will negatively effect CCT codes

By Dustin Thomas, MD, FSCCT

Late Monday, July 29, 2019, the Centers for Medicare and Medicaid Services (CMS) posted the Proposed Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Prospective Payment System (OPPS) Rules for 2020.  These comprehensive rules contain proposed policy and payment changes under the Medicare program.

Under the proposed 2020 OPPS rule, there is a reduction in the technical component (TC) reimbursement amounts for some imaging Ambulatory Payment Classification (APC) groups.   Cardiac CT services are grouped in an APC that would see a reduction in reimbursement.  There are multiple factors that may account for this proposed reduction, including the addition of a new subset of claims that CMS uses to determine rate setting, and the submission of claims that are grossly inaccurate.

A snapshot of professional and technical component reimbursement amounts for CCTA codes:

What you need to know about the proposed rule

MEDICARE PHYSICIAN FEE SCHEDULE (MPFS)

• Conversion Factor
  CMS estimates a conversion factor of $36.09, a slight increase from the 2019 conversion factor of $36.04.

• Payment for Evaluation and Management (E/M) Services
  CMS proposes to retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise the code definitions.  CMS proposes to adopt the AMA RUC-recommended values for the office/outpatient E/M visit codes for CY 2021 and the new add-on CPT code for prolonged service time.  The AMA RUC-recommended values would increase payment for office/outpatient E/M visits. 
  
  If finalized, this proposed new E/M structure would result in reimbursement cuts for some medical specialties and increases for others.  For example, CMS projects reimbursement cuts to radiology of -8% and -5% for nuclear medicine while cardiology would gain 3%. However, these projections are based on each specialty as a whole and could vary widely between services within each specialty. 

• Merit-Based Incentive Payment System (MIPS)
  CMS acknowledged concerns from clinicians and stakeholders about the complexity, burden, lack of performance comparability, questionable meaningfulness and lack of patient focused measurement within the MIPS program. With that in mind, CMS is proposing the MIPS Value Pathways (MVPs), a conceptual participation framework for future proposals beginning with the 2021 performance year. MVPs would utilize sets of 106 measures and activities promoting interoperability and administrative claims-based population health measures layered with specialty/condition specific clinical quality measures to create both more uniformity and simplicity in measure reporting.

 CMS proposed MPFS rule fact sheet                                                Full proposed MPFS rule                                            

HOSPITAL OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (HOPPS)

The HOPPS proposed rule includes proposals that would advance CMS’s commitment to increasing price transparency. CMS proposes that hospitals make public their “standard charges” for all items and services provided by the hospital. Furthermore, hospitals must make public-payer specific negotiated charges for common shoppable services that are displayed and packaged in a consumer friendly manner.

CMS proposes to increase the conversion factor by 2.7 percent bringing it up to $81.398 for CY 2020. 

Medicare uses claims data to determine rate setting for the APCs.  When a facility submits an actual claim of $27.88 for CPT 75574 and $0.48 for CPT 75571, this ensures a negative reimbursement trend for CCTA services. It is therefore imperative that claims submitted to CMS must be thorough and accurate and reflect the true cost of providing cardiac CT services. 

Beginning in CY 2020, CMS proposes to fully implement the CT and MR cost data regardless of the cost allocation method. SCCT has expressed concerns to CMS in the past regarding the use of claims from hospitals that continue to report under the “square foot” cost allocation method noting that it would under-estimate the true costs of CT and MR studies. Nevertheless, CMS has given hospitals six years to adjust their cost allocation methods from “square foot” to either “direct” or the “dollar” method.

There is a reduction in the technical component (TC) reimbursement amounts for some imaging Ambulatory Payment Classification (APC) groups.  All services in an APC group are assigned the same reimbursement.  Cardiac CT services are relatively low volume compared to services that share the same APC.  Higher volume services drive reimbursement for the APC.

 CMS proposed HOPPS rule fact sheet                                                Full proposed HOPPS rule                                            

What you can do?

• Submit comments electronically to CMS by September 27. Please refer to file code CMS-1715-P for the MPFS proposed rule and CMS-1717-P for the Outpatient Prospective Payment System proposed rule.
• You need to contact your institution’s administrators to call attention to any coding anomalies. Ask your CFO to conduct a review in your institution. You can make a difference!

What is SCCT doing?

• A full analysis of to impact of the proposed rules.
• Submit formal comments to CMS on behalf of all our members.
• Keep you up-to-day with the changes through announcements, newsletters and social media.
• Offer tools on how local efforts can improve national coverage.

Final rules are expected to be published on or around November 1, 2019.