SNMMI Call to Action: Submit Your Comments on Medicare Proposed Rules

September 18, 2019

The Story

The Centers for Medicare and Medicaid Services (CMS) released the calendar year 2020 Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Prospective Payment System (HOPPS) proposed rules in July. Some of the changes proposed greatly impact nuclear medicine and molecular imaging reimbursement.

• In the HOPPS setting, some of the Ambulatory Payment Classification (APC) placements are not appropriate.
• In the MPFS setting some of the proposals for myocardial PET could potentially lead to technical component payment reductions as high as 80 percent for some services. The MPFS rule revisions result from updates to the current procedural terminology (CPT) codes used to report these services and review of the direct practice expense inputs that inform the calculation for the technical component payment.

The society—along with the American College of Nuclear Medicine—have already submitted comments alerting CMS to the impact of these proposals. We need your help in submitting comments as well. CMS needs to hear how these proposals impact your profession and patient care. This is your chance to be heard!

Why It’s Important

CMS uses the Medicare Physician Fee Schedule to reimburse physician services. The MPFS is financed by Part B and comprises resource costs associated with physician work, practice expense, and professional liability insurance.

CMS uses the HOPPS to reimburse for hospital outpatient services. The HOPPS was created to minimize beneficiary copayments in response to rapidly growing Medicare expenditures for outpatient services and large copayments being made by Medicare beneficiaries. Outpatient services covered belong to an APC group. Each group of procedures (i.e., codes) within an APC is presumed to be “similar clinically and with regard to resource consumption.”

How You Can Help

For Providers Billing in the Hospital Outpatient Setting- HOPPS

SNMMI and ACNM recommend improvements in the way that CMS pays hospital outpatient departments for nuclear medicine and molecular imaging procedures.

Send your own personalized comment—with any of the points noted above—to CMS directly, adding your own comments on the impact of these proposals, including the impact on patient care from your perspective.

The letter includes our strong requests to:

1. Change APC placements for new and re vised nuclear medicine CPT codes effective January 1, 2020.
2. Place CPT codes 78803 in APC group 5593 rather than 5592
   1. CPT 78607 (brain SPECT imaging) is being deleted and effectively replaced by either CPT 78803 or 78830. Rates for 78803 for brain imaging would be reduced by 155%, and that is not the intent of the coding changes; therefore, we need to URGE CMS to move CPT 78803 into APC group 5593 rather than the proposed 5592. This request is supported by the HOPPS claims data weighted average.
3. Place CPT codes 78X29, 78804 and 788X1 into APC group 5594
4. Place CPT 78X32 in APC 1522, CPT 78X33 in APC 1523, and CPT 78X34 in APC 1523
5. Add payments for non-LEU sourced radiopharmaceuticals
   1. Requests that CMS finalizes the continuation of separate payment for Q9969 for CY 2020

Please send your comments on HOPPS to CMS before September 27 at 5 pm ET.

For Providers Billing in the Medicare Physician Fee Schedule -MPFS

SNMMI and ACNM has submitted a comment letter on the proposed rule for the MPFS recommending corrections in the way that CMS calculates the inputs and accepts invoices for use in the payment formula for the new CPT codes for nuclear medicine and molecular imaging procedures, specifically for CY 2020 myocardial PET and SPECT and SPECT-CT procedures. Many thanks to those members who provided additional invoices, which we included in our submissions as a summary table and supplemental materials.

In response to alarming proposed reimbursement cuts to cardiac PET included in the proposed 2020 Medicare Physician Fee Schedule, SNMMI, ACNM, ASNC and ACC partnered to launch a robust advocacy effort, asking for support from Congress and providing compelling information and data to CMS on the true cost of providing cardiac PET.

The letter includes our strong requests to CMS:

Professional Component Recommendations

1. CMS should accept the RUC professional component RVWs, as they are based on surveys and RUC validated methods.

Technical Component Recommendations

2. CMS should use the 50% equipment utilization rate for all nuclear medicine services rather than the proposed 90% utilization rate.
3. We agree with CMS 5-year equipment life, rather than 7-year RUC utilization as this technology is evolving.
4. CMS should accept all the medical society (SNMMI, ACNM) direct practice expense refinements.
5. CMS should accept more invoices for pricing the nuclear medicine equipment.
6. CMS should accept the software and equipment items and inputs for CPT 78434, as they did for the SPECT quantification code.

Please send your comments on MPFS to CMS before September 27 at 5 pm ET.

Additional Resources:

Background regarding the new and revised 2020 CPT codes

SNMMI-ACNM Comments on 2020 Medicare Physician Fee Schedule

SNMMI-ACNM Comments on 2020 Hospital Outpatient Prospective Payment System

SNMMI Webinar and Highlights on 2020 Code Updates and Changes

Next Steps

CMS will publish both HOPPS and MPFS final rules around November 1, 2019. SNMMI will notify our members via our web site and notices when they are available. Thank you for your help!