Medicare’s final CY2025 HOPPS and MPFS rules bring a significant but temporary boost to CCTA reimbursement. Outpatient payments will more than double, rising from $175 to $357 under APC 5572, while the global MPFS payment increases to $318. These updates reflect CMS’s recognition of CCTA’s resource intensity, diagnostic value, and its efforts to correct long-standing revenue code issues (see link to revenue code). The temporary adjustment aims to gather sufficient data over the next 3–4 years to evaluate a permanent change. After this period, CMS will review the data to determine whether to keep CCTA in APC 5572 or revert to the lower APC 5571 classification.

With better reimbursement, more hospitals and outpatient centers may offer CCTA, making this advanced diagnostic tool more widely available. Increased access is particularly beneficial for patients in underserved or rural areas, where advanced imaging services may have been limited. Increased utilization can lead to earlier and more precise diagnosis of coronary artery disease, allowing for timely interventions and potentially preventing severe outcomes, like heart attack.
Aligning reimbursement rates with the actual costs of performing CCTA makes the procedure more economically viable for hospitals and providers, ensuring sustainability and preventing financial barriers from limiting patient access.

The Ambulatory Payment Classification (APC) is a system used by CMS under the OPPS to determine the reimbursement rates for outpatient services provided by hospitals. It groups similar healthcare services defined by CPT/HCPCS codes together for the purpose of payment, based on the resources required to provide those services.

1. Engage your revenue cycle team: Begin by identifying your health system's revenue cycle administrators. In larger organizations, this process typically starts with your division or department administrator or practice manager, who can guide you
2. Educate on correct billing practices: Schedule a meeting with the identified administrator(s) to discuss the importance of proper billing for CCTA. Emphasize the need to use a cardiology revenue code (0480), when appropriate, instead of the more general radiology revenue code (0350). Accurate coding is critical for capturing the true utilization and resource needs of CCTA, ensuring its value is reflected in the data CMS reviews.
3. Establish tracking mechanisms: Ask your administrator about ways to monitor billing practices at your institution and identify potential denials, particularly in cases where there may be resistance to using the cardiology revenue code. Understanding how billing is processed and tracked can help identify discrepancies that could influence CMS's evaluation.
4. Provide feedback to SCCT: Any insights or challenges you encounter in your institution—such as pushback on billing practices or denials —can provide valuable feedback to SCCT. This information is crucial not only for educating SCCT members but also for supporting advocacy efforts with CMS.
   

1. Document the denial: Record any details or reasoning provided for the denial.
2. Seek clarification: Consult your administrator to understand the specific cause of the denial.
3. Share with SCCT: Forward any non-patient-specific details to SCCT for tracking and further analysis.
   

Maintained by the National Uniform Billing Committee (NUBC), an entity designated by the Health Insurance Portability and Accountability Act (HIPAA), revenue codes describe the type or location of services for the various charge master amounts billed for hospital services provided to a patient. The revenue code tells an insurance company whether the procedure was performed in the emergency room, operating room or another department. CMS instructs that hospitals are advised to use the most appropriate revenue code, and expects hospitals to match expenses to revenue via revenue code selection.

Revenue codes are essential for accurate billing and reimbursement. They provide a standardized method to classify services, allowing facilities to submit claims to insurance companies or government payers for payment. In addition, they help insurers verify the medical necessity and payment of claims.

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Yes. At many hospitals, CCTA can use resources across departments. If this is true of your hospital — for example, the current hospital department where the specially trained nurses and other test expenses are currently recorded is a cardiology cost center — then it may be appropriate to use the revenue code 0480. Medicare wants the revenue code to reflect the type of cost center where operating costs reside.

Yes, it is possible. Hospitals do not need to consider where the expense of the CT equipment itself is recorded. Medicare wants the revenue code to reflect the type of cost center where operating costs reside. At many hospitals, CCTA can use resources across departments. If this is true of your hospital — for example, the hospital department where the specially trained nurses and other test expenses are   recorded is a cardiology cost center — then it may be appropriate to use the revenue code 0480.

In this case, you can reference Section 20.5 in Chapter 4 (Part B Hospital) of the CMS Medicare Claims Processing Manual that states: [CMS] “does not instruct hospitals on the assignment of HCPCS codes to revenue codes for services provided under OPPS since hospitals’ assignment of cost vary. Where explicit instructions are not provided, HOPDs should report their charges under the revenue code that will result in the charges being assigned to the same cost center to which the cost of those services are assigned in the cost report.” Hospital outpatient facilities must determine the most appropriate cost center and revenue code for the cardiac CT codes.

A revenue code change to cardiology is warranted if the hospital department where the specially trained nurses and other test expenses are recorded is a cardiology cost center. Do not consider where the expense of the CT equipment itself is recorded. If that department is CT, then the revenue code remains 350. If that department is cardiology, then the revenue code should change to 480. The hospital’s and clinicians’ management, protocols, SOPs, etc. of these tests are not changing at all.

The Hospital Outpatient Prospective Payment System (OPPS) is a payment system used by Medicare to reimburse hospitals for outpatient services. Under this system, hospitals are paid a fixed amount for each outpatient service they provide, based on the Ambulatory Payment Classification (APC) system. The OPPS aims to create more predictable, standardized payments for hospitals while incentivizing efficiency in the delivery of care.

Key features of OPPS:

1. APC-based payments: Services provided in outpatient settings are categorized into various groups called APCs, which determine the reimbursement amount. Each APC corresponds to a set of related services that are typically performed together and are reimbursed at a fixed rate. For example, certain procedures or diagnostic tests that are often performed together may fall under one APC and receive a fixed payment.
2. Payment methodology: OPPS uses a prospective payment model, meaning the payment rate is set in advance based on historical cost data, service codes, and the nature of the procedure or service. Hospitals do not receive payment based on the actual costs incurred during the treatment, but rather according to the pre-determined rates for each APC.
3. Payment adjustments: Payments may be adjusted for factors like the geographic location of the hospital (due to regional cost variations) or the complexity of the service provided. Additional adjustments can also be made for certain hospital characteristics, such as teaching status or the provision of care to underserved populations.
4. Quality reporting: Hospitals must meet certain quality reporting requirements to receive the full payment. If they fail to report on designated quality measures, they may face payment reductions.
5. Outpatient setting: OPPS applies specifically to outpatient services provided in hospital settings, such as emergency department visits, outpatient surgeries, diagnostic tests, and certain therapeutic services. It does not cover inpatient services, which are reimbursed under a different system (Inpatient Prospective Payment System, IPPS).

The goal of OPPS is to improve efficiency and reduce unnecessary costs while ensuring that hospitals are reimbursed for the services they provide. It also allows for a more predictable payment system for outpatient care, making it easier for Medicare to budget for these services 

The Medicare Physician Fee Schedule (MPFS) is a payment system used by Medicare to reimburse healthcare providers for services provided to Medicare beneficiaries. The MPFS sets the rates Medicare will pay for a wide range of services that are provided by physicians and other eligible practitioners in an outpatient setting.

Key Features of the Medicare Physician Fee Schedule (MPFS):

1. Service codes (CPT/HCPCS codes):
   1. The MPFS is based on the Current Procedural Terminology (CPT) codes and the Healthcare Common Procedure Coding System (HCPCS) codes, which are used to identify specific services and procedures.
   2. Each code represents a specific medical service or procedure that a physician may perform, such as consultations, diagnostic tests, surgeries, or preventive care.
2. Payment rates:
   1. Medicare determines the payment rates for each service based on a calculation called the Resource-Based Relative Value Scale (RBRVS).
   2. RBRVS assigns a "relative value" to each service, based on the resources (time, skill, equipment, and overhead) required to perform it. These relative values are then adjusted for geographic location (due to varying costs across regions) and updated annually by Medicare.
   3. The formula for the MPFS involves multiplying the relative value by a conversion factor, which is a national value set by Medicare to standardize payments.
3. Payment adjustments:
   1. Payments may be adjusted depending on several factors:
      1. Geographic Practice Cost Indices (GPCI): Adjustments made to reflect the differences in the cost of living and practice expenses in various regions of the United States.
      2. Specialty adjustments: Certain specialties, such as primary care, may receive higher payment rates to encourage participation.
      3. Quality Reporting and Value-Based Adjustments: Medicare has implemented programs that tie payment to quality measures, such as the Merit-based Incentive Payment System (MIPS), where providers can earn bonuses or face penalties based on performance on quality measures.
4. Scope of services:
   1. The MPFS covers a wide range of services, including:
      1. Physician visits (e.g., office consultations, inpatient visits)
      2. Diagnostic tests (e.g., lab work, imaging)
      3. Preventive care (e.g., screenings, immunizations)
      4. Minor surgeries and procedures
   2. It does not typically cover hospital inpatient services (which are covered under the Inpatient Prospective Payment System, IPPS).
5. Annual updates:
   1. Medicare updates the Physician Fee Schedule each year, taking into account changes in the healthcare market, the costs associated with providing care, and adjustments in medical technology.
   2. These updates are part of the Medicare Physician Fee Schedule Final Rule, which is published annually by the Centers for Medicare and Medicaid Services (CMS).

   Example of MPFS payment calculation:
   

   • If a physician performs a service with a relative value of 2.0 (based on the RBRVS system), the geographic practice cost index (GPCI) for their region is 1.1, and the conversion factor is $36.00:
   •  
   •  Payment = 2.0 (RVU) × 1.1 (GPCI) × $36.00 (conversion factor) = $79.20

The MPFS is crucial for ensuring that healthcare providers are reimbursed fairly for services they provide to Medicare beneficiaries. It also serves as a mechanism for encouraging efficiency, quality care, and the proper allocation of healthcare resources.

The HOPPS and the MPFS are both payment systems used by Medicare to reimburse healthcare providers for services provided to Medicare beneficiaries. However, they apply to different settings and services, and each has its own methodology for determining payments. Here's a breakdown of how they align and differ:

Alignment:

• Both systems involve fixed payment amounts for services, though the methods of determining those payments differ (fixed per service under HOPPS, based on relative value units under MPFS).
• Both systems use coding systems to determine reimbursement. HOPPS uses Ambulatory Payment Classifications (APCs) based on service types, while MPFS uses CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) codes that describe individual medical services and procedures.

In terms of differences:

• HOPPS applies to outpatient services provided by hospitals. MPFS applies to services provided by individual healthcare professionals, including physicians, nurse practitioners, physician assistants, and certain other non-physician providers, but not hospital inpatient services.
• HOPPS payments are more hospital-specific, often adjusted for factors like geographic location and certain hospital characteristics (e.g., teaching status, disproportionate share hospital (DSH) adjustments). MPFS payments are based on individual providers and are generally set for a broad range of specialties. They are adjusted based on geographic cost differences using Geographic Practice Cost Indices (GPCI) and other factors relevant to the provider's location.

Medicare often uses cost data from both systems to inform payment updates. For example, trends in outpatient care costs under HOPPS may influence adjustments in payment rates under MPFS, particularly for services commonly provided in both hospital outpatient and physician office settings.