CMS Issues Final Rules for 2018

November 3, 2017

The Centers for Medicare and Medicaid Services (CMS) has released a total of 4,036 pages in the Federal Register describing changes for Medicare in 2018. This is a preliminary summary of rules affecting nuclear medicine and molecular imaging. There are some new tweaks for this specialty, but no major surprises or changes.

Three rules were released. They are the Physician Fee Schedule (PFS) rule, the Hospital Outpatient Prospective Payment System (OPPS) rule and the Quality Payment Program (QPP) rule. The rules all take effect on January 1, 2018.

Physician Fee Schedule

In the PFS rule, CMS estimates that payments to nuclear medicine physicians (and most physicians) will see a 0.3 percent increase in payments in 2018. The mandate that referring physician consult Appropriate Use Criteria (AUCs) is pushed back from 2018 to 2020.

For individual rates, see the SNMMI detailed chart

Hospital Outpatient Prospective Payment Rule

The OPPS rule includes an overall 1.4 percent payment increase for 2018. CMS again rejected our recommendations to create separate ambulatory patient classifications (APCs) for high value radiopharmaceuticals.

All nuclear medicine procedure rates have positive increases in payments for CY 2018, some modest and others larger. For individual rates, see the SNMMI detailed chart.

The HCPCS committee did not agree to create new “per study dose” codes for gallium-68-DOTATATE or Fluciciovine, as those remain per 0.1 millicurie or per 1 millicurie. Therefore, there are no changes to how you report those products.

We have also prepared a high-level PowerPoint of the nuclear medicine APC rates for procedures:

Other items:

  • CMS deleted the A9599 unlisted amyloid code, as they have created the unlisted non-tumor and unlisted tumor RP codes for use of any new PET tracers.
  • CMS is adopting a policy to pay separately for non-pass-through drugs and biologicals (other than vaccines) purchased through the 340B Program at the average sales price (ASP) minus 22.5 percent, rather than ASP plus 6 percent.
  • CMS is reinstating the non-enforcement of direct supervision requirements for outpatient therapeutic services for CAHs and small rural hospitals having 100 or fewer beds for CYs 2018 and 2019.

 The Quality Payment Program

On the QPP front, CMS described changes in the second transition year for the Merit-Based Incentives Payment System (MIPS) and for Advanced Alternative Payment Models (APMs).

They surprisingly decided to start measuring the costs of physicians as 10 percent of a physicians’ Merit-Based Incentive Payment System (MIPS) score. The cost measurement system is widely considered to be rudimentary at best. Based on 2018 performance, clinicians and groups will be eligible to receive a payment bonus or penalty of up to 5 percent in 2020 under MIPS.

For More Information

Links to the rules and CMS summaries of these rules are available below: