CMS Publishes MPFS and OPPS Final Rules Expanding Coverage for Non-Oncologic PET

November 9, 2021

Last week,  the Centers for Medicare and Medicaid Services (CMS) finalized its Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Prospective System (OPPS) rules. The following are the highlights of the rules which impact nuclear medicine.

  • CMS removed the "exclusionary language" from NCD 220.6 Positron Emission Tomography (PET) Scans. This will leave non-oncologic PET indications (unless noted by NCD 220.6.1-220.6.20) to the discretion of local Medicare Administrative Contractors (MACs). We applaud CMS’s coverage decision, which results from years of work by SNMMI and our industry partners. We resoundingly agree that “local contractor discretion provides an immediate avenue to potential coverage in appropriate candidates for non-oncologic indications.” Various new PET agents for non-oncologic indications are currently in FDA trials. Retiring the national non-coverage policy for non-oncologic indications upon the agents’ FDA approval will eliminate the regulatory “bottleneck” leading to Medicare beneficiary access issues.  
  • To our dismay, the PFS final rule cuts the conversion factor to $33.59 in CY 2022, as compared to $34.89 in CY 2021; this follows the expiration of the 3.75% payment increase, a 0.00% conversion factor update, and a budget neutrality adjustment. SNMMI is working with the medical community to prevent cuts to physician reimbursement. Click here to send a letter to Congress to avert these cuts.
  • CMS delayed the implementation of the payment penalty phase of the Appropriate Use Criteria program to the later of Jan. 1, 2023, or the Jan. 1 that follows the end of the public health emergency. 
  • Thankfully, CMS listened to our concerns regarding practice expense inputs. CMS will be phasing in the clinical staff wage increase over 4 years. Therefore, the impact to nuclear medicine procedure codes will not be felt as badly as in the proposed rule (3-4% decrease versus a 10-15% decrease).
  • The final CY 2022 OPPS Rule did not include any changes to the inequitable reimbursement policy of precision diagnostic radiopharmaceuticals. These drugs continue to be packaged after the expiration of a 3-year pass-through period. To send a letter to Congress in support of the Facilitating Innovative Nuclear Diagnostics (FIND) Act, legislation aiming to expand patient access through appropriate payment, please click here.

The CY 2022 final Medicare Physician Fee Schedule Chart may be found here.

The CY 2022 final Hospital Outpatient Prospective Payment System Schedule Chart may be found here.