On November 2, 2018, the U.S. Centers for Medicare and Medicaid Services (CMS) issued the Final 2019 Rule on the Hospital Outpatient Prospective Payment System (OPPS). This rule governs technical component reimbursement for medical services provided in the hospital outpatient setting.
Under the OPPS, CMS assigns each individual medical service (i.e., each individual HCPCS code) to an Ambulatory Payment Classification (APC) group, and all services included within a designated APC group are reimbursed at the same rate. By law, all services included within a single APC group are required to be similar clinically and in resource use. Unfortunately, over the last several years CMS has loosened its interpretation of clinical homogeneity and as a result has grouped clinically dissimilar services together in APCs; this has resulted in a marked and significant decline in technical component reimbursement for a number of imaging services, including some CMR codes. For 2019, CMS has largely maintained the placement of CMR codes in the same APC groups as prior years, except that CPT 75559 (CMR with stress/without contrast, e.g., dobutamine stress CMR) has been moved into a higher level APC, resulting in an appreciable (103%) increase in technical component reimbursement for this service. Of the other CMR codes, reimbursement rates for 75557 (CMR without contrast/without stress), and 75563 (CMR with stress/with contrast, e.g., vasodilator stress perfusion CMR), remain relatively unchanged, while 75561 (resting CMR with contrast) reimbursement unfortunately decreases by nearly 15%. The SCMR submitted a letter to CMS contesting this decrease as being potentially disruptive to clinical practice, but CMS countered that the cost data for this code does not support placement into a higher level APC.
For comparison purposes, the chart below lists the technical and professional component reimbursement rates for 2017, 2018, and 2019 for cardiac MR, cardiac CT, echocardiography, and cardiac SPECT. Technical component reimbursement is intended to reflect the non-physician costs of the procedure. The inequities between the reimbursement rates for the various modalities underscores the lack of reliable data on the true costs of performing a CMR exam. CMS sets reimbursement rates solely based on cost data obtained from a small subset of Medicare claims. There is an urgent need for all facilities to accurately capture the cost of each and every component of providing a CMR service when submitting a Medicare claim. Hospital charge masters should be updated to appropriately reflect these costs. Without adequate data that reflects the true cost of providing CMR services, reimbursement will continue to decline. Be assured that SCMR continues to engage CMS in a dialogue regarding the need improve reimbursement for CMR services. We have also urged CMS to identify ways to better place low volume services, such as CMR, in APCs that will more appropriately reflect adequate reimbursement for CMR services.
SCMR will continue its analysis of the final OPPS rule for 2019. For additional information, please see this CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center. The issue of appropriate claims submission will be highlighted during the US Working Group Meeting, Friday, February 8, at the SCMR Annual Scientific Sessions in Seattle.
CMR Codes
CT Codes
Echo Codes
SPECT Codes
*The Medicare Physician Fee Schedule (MPFS) includes professional component reimbursement and technical component reimbursement for services provided in the office setting.
**The Hospital Outpatient Prospective Payment System (OPPS) includes technical component reimbursement for services provided in the outpatient setting. Professional component reimbursement is provided under the MPFS.
Sources of payment rate calculations:
2018 Final Medicare Physician Fee Schedule Rule
2019 Final Medicare Physician Fee Schedule Rule
2017 Final Hospital Outpatient Prospective Payment System Rule
2018 Final Hospital Outpatient Prospective Payment System Rule
2019 Final Hospital Outpatient Prospective Payment System Rule
