Good News for Nuclear Medicine in CMS Final 2020 MPFS and HOPPS Rules

November 4, 2019

THE STORY

When the Centers for Medicare and Medicaid Services (CMS) released its proposed MPFS and HOPPS rule in July, they included changes that could have seriously affected reimbursement for nuclear medicine and molecular imaging procedures.

But on Friday, November 1, when CMS released the 2020 Medicare Physician Fee Schedule (MPFS) final rule and the 2020 Hospital Outpatient Prospective Payment System (HOPPS) final rule, there was good news for nuclear medicine.

WHY IT’S IMPORTANT

  • Rather than facing technical component cuts of as much as 80 percent to myocardial PET reimbursement, the technical component will continue to be paid according to contractor pricing in 2020.

  • Instead of a 157% decrease in reimbursement for some SPECT and SPECT-CT studies, there is a 3.5% INCREASE in reimbursement.

WHAT SNMMI DID

  • SNMMI met with CMS, discussed the impact of their proposed policy changes on nuclear medicine and molecular imaging services, and submitted extensive comments to the agency.
  • SNMMI worked actively with the American College of Cardiology (ACC), American College of Nuclear Medicine (ACNM), the American Society of Nuclear Cardiology (ASNC), and Cardiology Advocacy Alliance (CAA) and other stakeholders to compile detailed comments on MPFS and HOPPS for CMS.
  • SNMMI members sent personalized comments to CMS, including the potential impact on care of their patients.
  • SNMMI members provided invoices, which SNMMI included in its submissions and supplemental materials.

SNMMI thanks members for sending in comments, but most of all, for providing invoices, which helped convey to CMS the cost of making these services available to patients!

THE RESULTS

Major successes for SNMMI included in the MPFS final rule:

  • CMS proposed to reduce the myocardial PET professional payments by as much as 26% percentage however were convinced to roughly maintain the current professional values.
  • CMS agreed to continue with contractor pricing for the technical fee for myocardial PET for 2020 to give more time on inputs.
  • CMS agreed to accept the 50% equipment utilization rate rather than 90% utilization.
  • CMS agreed with the majority of the invoices SNMMI submitted for PET, PET-CT and SPECT-CT and updated all the equipment rates accordingly.
  • CMS accepted SNMMI's rationale for all other times and updated supplies and times for clinical staff inputs for both SPECT and cardiac PET.
  • CMS agreed with all submitted SPECT-CT invoices and updated all the equipment rates accordingly (proposed cost equipment $464,428 to $703,443). CMS will move to fully implement these rates rather than phase in, due to their oversight.

Major successes for SNMMI included in the HOPPS final rule:

  • Instead of a significant decrease in reimbursement for SPECT studies, SNMMI members will see an increase. CMS accepted all SNMMI’s revised placements for all the new SPECT and SPECT-CT services into appropriate APC groups. For SPECT studies, some would have seen as much as a 157 percent decrease. With SNMMI’s intervention, those procedures will now see a 3.5 percent increase. This was based on a detailed weighted average analysis of the SPECT deleted codes conducted by the SNMMI. CMS then reviewed the codes and agreed it would be appropriate to reassign CPT code 78803 to APC 5593.
  • For 2020, new PET and PET-CT CPT codes will be paid at an appropriate rate. CMS accepted the jointly prepared new technology application for alternative placements in for the new PET and PET-CT CPT codes. CMS agreed to temporarily place these services in new technology categories while they collect charge and cost data from hospitals for future rule placements, rather than putting them in a potentially inappropriate APC group.

Finally, CMS made no changes regarding implementation of the mandate requiring that clinicians consult appropriate use criteria (AUC) through a qualified clinical decision support mechanism (CDSM) starting Jan. 1, 2020, when ordering advanced imaging services (i.e., SPECT/PET MPI, CT and MR). CMS posted requirements in a MLN Matters article published in July 2019.

WHAT’S NEXT

  • SNMMI will continue to collect additional information as necessary to help inform CMS of the cost of making cardiac PET accessible to patients.
  • CMS will continue to review the inputs and encourage the public to submit additional information on the most accurate resource-based payment for these services by the February 10 deadline for consideration in future rule making.
  • SNMMI will hold a webinar on December 5 to review the new codes and the payment rates in the different settings. Check the SNMMI website next week for more information!