CMS Proposes 2019 Outpatient Payment Rules

July 26, 2018

CMS released the 761-page Proposed Hospital Outpatient Payment Rule for 2019. There are no major changes for nuclear medicine, and fees are projected to go up a little:

The followng RPs will stay on pass-through (see p. 264)

    • A9586 Florbetapir f18, diagnostic, per study dose, up to 10 millicuries, APC 9084
    • A9587 Gallium ga-68, dotatate, diagnostic, 0.1 millicurie, APC 9084
    • A9588 Fluciclovine, F18, diagnostic, 1 millicurie, APC 9056
    • C9031 Lutetium Lu 177, dotatate, therapeutic, 1 mCi, APC 9067

 These RPs will go off:

    • A9515 Choline C11, diagnostic, per study dose, APC 9461
    • Q9982 Flutemetamol F18, diagnostic per study dose, up to 5 millicuries, APC 9459
    • Q9983 Florbetaben F18, diagnostic per study dose, up to 8.1 millicuries, APC 458

This RP gets the special 2-year exemption from going off the pass-through list due to provisions put in the 2019 budget bill to benefit an ophthalmic drug manufacturer:

  • Florbetapir f18 (coverage is the problem for this RP).

CMS is staying steadfast by its plans to reduce the number of bundles saying “Our overarching goal is to make payments for all services under the OPPS more consistent with those of a prospective payment system and less like those of a per-service fee schedule, which pays separately for each coded item. As a part of this effort, we have continued to examine the payment for items and services provided under the OPPS to determine which OPPS services can be packaged to further achieve the objective of advancing the OPPS toward a more prospective payment system.” (See p.85)

CMS also is not planning to change its $10 add-on payment for LEU sourced Mo-99. (See p. 302) However, they will need to reverse a change in the status of the code used to bill for this.

Now that many physician practices have been bought by hospitals, CMS is realizing it’s paying for more “hospital” visits, which cost more than office visits, so they want to cut the pay for these hospital visits.

They are also looking to move more simple procedures back out of the hospital and are putting more procedures on the ASC list as well. (See pages 355, 374)

SNMMI will be responding to the rule in late September. For a summary the proposed physician payment rule and other recent advocacy activity, click here.