On November 1, 2017, the Centers for Medicare and Medicaid Services (CMS) released the final rule on the 2018 Hospital Outpatient Prospective Payment System (OPPS).  This rule updates reimbursement rates for technical component payment and policy changes for services provided in the hospital outpatient department setting.  Payment rates for cardiac CT services (CPT 75572, 75573, and 75574) are down slightly as compared to 2017 rates (see attached chart with reimbursement comparisons).  However, payment for CPT 75571 (calcium score) is up. 

CMS considers Medicare claims data in order to inform payment rates under the OPPS.  By law, services are to be assigned to an  Ambulatory Payment Classification (APC) group along with other services that are similar clinically and in resource use.  CMS implemented an extensive consolidation and restructuring of the imaging APCs over the last two years.  SCCT argued that CMS should maintain the current APC structure for now to allow stability in the payment system and time for additional data to be collected.   This highlights the need for accurate claims data. 

Accurate charges are essential

Hospitals should update charge masters and account appropriately for each and every component of providing a cardiac CT service.  Payment rates will not improve if accurate cost accounting is not in place.  We encourage U.S. members of SCCT to highlight this issue at your own institution. 

Related to this, on November 2, 2017, CMS issued the final rule on the Medicare Physician Fee Schedule (MPFS) for 2018.  This rule sets payment updates for the fee schedule and includes policy changes governing the provision of services under Medicare Part B.   For 2018, professional component payment for cardiac CT services (CPT 75571, 75572, 75573 and 75574) remains relatively stable as compared to 2017 (see chart for reimbursement comparisons). 

This rule also clarifies that CMS plans to further delay the implementation of the Medicare Appropriate Use Criteria mandate.  As you will recall, the law requires CMS to implement an AUC program for advanced diagnostic imaging services provided to Medicare beneficiaries.  Under the program, a provider who orders an advanced diagnostic imaging test must consult with AUC using a qualified clinical decision support mechanism. Professionals who furnish the imaging test must attest that the ordering professional consulted AUC.  CMS has agreed to delay the effective date of this program until January 1, 2020.  CMS will consider 2020 as an educational and operational testing period.  CMS will develop a consultation identifier for reporting on Medicare claims.

For information on the overarching provisions of both rules,  please see the following CMS Fact Sheets:  

CMS Issues Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System and Quality Reporting Programs Changes for 2018 (CMS-1678-FC)

Final Policy, Payment, and Quality Provisions in the Medicare Physician Fee Schedule for Calendar Year 2018

2018 Final MPFS and OPPS chart imaging updates