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2021 Proposed Medicare Payment Rules

Wednesday, August 26, 2020   (0 Comments)
Posted by: SCMR Admin
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2021 Proposed Medicare Payment Rules

On August 4, 2020, the U.S. Centers for Medicare and Medicaid Services (CMS) issued the proposed 2021 Hospital Outpatient Prospective Payment System (OPPS) and proposed 2021 Medicare Physician Fee Schedule (PFS) rules.  These rules govern Medicare payment and other policies applicable to physicians and hospital outpatient departments. 

Hospital Outpatient Prospective Payment System (OPPS)

The OPPS payment provisions apply to technical component (TC) 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 grouped within a designated APC group are reimbursed at the same rate.  According to statute, 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 consolidated the number of imaging APCs in addition to applying varying interpretations of clinical homogeneity.  As a result, CMS has grouped clinically dissimilar services together.  This creates a marked and significant decline in technical component reimbursement for many imaging services, including cardiovascular magnetic resonance (CMR) services.

OPPS TC Payment Amounts

For 2021, SCMR is pleased to see a proposed increase in OPPS TC reimbursement for several CMR Current Procedural Terminology (CPT) codes.  However, there is a slight decrease in reimbursement proposed for CPT 75561.

CPT code

Descriptor

2020 Final OPPS rule 

2021 Proposed OPPS rule

Variance %

Variance $

75557   

Cardiac MR imaging for struct and morph w/o contrast

 $ 233.01

 $ 235.01

1%

 $ 2.00

75559   

Cardiac MR imaging for struct and morph w/o contrast w/stress imaging 

 $ 481.53

 $ 490.52

2%

 $ 8.99

75561 

Cardiac MR imaging for struct and morph w/o contrast, followed by contrast, and further sequences

 $ 381.81

 $ 375.33

-2%

 $ (6.48)

75563   

Cardiac MR imaging for struct and morph w/o contrast, followed by contrast, and further sequences, w/stress imaging.

 $ 680.74

 $ 722.74

6%

 $ 42.00

75565

Cardiac MR imaging for velocity flow mapping

N/A*

N/A*

-

-

* add on codes are not separately payable in OPPS

 

Medicare Physician Fee Schedule (PFS)

 

Conversion factor

 

The proposed calendar year (CY) 2021 PFS conversion factor is $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09.  Relative Value Units (RVUs) for physician work, practice expense, and malpractice expense are multiplied by the conversion factor (with adjustments for the Geographic Practice Cost Index) to determine payment.

 

This year, CMS has proposed a significant revision in the structure of evaluation and management (E/M) services for office and outpatient visits. These changes include retaining five (5) levels of coding for established patients, reduce to four (4) levels for new patients, and a new code for extended office visit time.

 

The AMA and others supported restructuring and revaluing the office-based E/M codes, which will increase payments for primary care and other office-based services. Unfortunately, by law, any changes to the PFS cannot increase or decrease expenditures by more than $20 million. To comply with this budget neutrality requirement, any increases must, therefore, be offset by corresponding decreases.

 

The end result of these shifts in spending means that some specialties, such as radiology, could see professional component reimbursement cuts up to -11 percent.  The House of Medicine is working hard to mitigate these reimbursement cuts especially in light of challenges associated with the provision of care during the COVID-19 pandemic.

 

Initial calculations for CMR services under the proposed PFS are:

 

CPT code

Descriptor

2020 Final PFS Payment (global)

2021 Proposed PFS Payment (global)

Variance %

Variance $

75557   

Cardiac MR imaging for struct and morph w/o contrast

 $     325.17

 $     303.24

-7%

$ (21.93)

75559   

Cardiac MR imaging for struct and morph w/o contrast w/stress imaging 

 $     451.48

 $     420.99

-7%

$ (30.49)

75561 

Cardiac MR imaging for struct and morph w/o contrast, followed by contrast, and further sequences

 $     426.58

 $     400.34

-6%

$ (26.24)

75563   

Cardiac MR imaging for struct and morph w/o contrast, followed by contrast, and further sequences, w/stress imaging.

 $     505.25

 $     475.18

-6%

$ (30.07)

75565

Cardiac MR imaging for velocity flow mapping

 $       53.41

 $       50.97

-5%

$ (2.44)

 

SCMR, as part of the American Medical Association (AMA) Specialty and Service Society (SSS) Caucus, will join with AMA stakeholder efforts to fight these proposed reimbursement cuts.

 

How You Can Help

While the OPPS proposed payment increases for 2021 represent a move toward what we believe is more fair and appropriate reimbursement, SCMR remains concerned about the apparent lack of reliable Medicare claims data on the true costs of performing CMR services, especially CPT 75561. The fact remains that reimbursement is a data driven process.  Under OPPS, CMS bases reimbursement on cost data obtained from a small subset of Medicare claims.  If claims do not capture the true costs of performing CMR services, reimbursement will continue to decline.  We need to be able to justify the movement of the CMR codes into APCs that would allow more fair and appropriate reimbursement. 

Last year, SCMR contracted with a health economics firm to analyze Medicare claims for CMR services.  We know that some facilities are not submitting reasonable claims to Medicare.  Importantly, we know that not all facilities use (nor are they required to use) the same method of cost accounting.  Therefore, there is a need for all U.S. members to establish a dialogue with their institution’s hospital finance experts.  Please call attention to the low reimbursement for the technical component of CMR services.  Ask them to reinforce the need 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 to reflect a true and accurate cost of providing CMR services, reimbursement will likely continue to decline. 

SCMR has created several documents to help guide your discussions.  These hospital toolkit documents are available on www.scmr.org

 

For More Information

SCMR will continue its analysis of the proposed OPPS and PFS rules for 2021.  Comments are due October 5, 2021.  The final rule provisions will take effect January 1, 2021.

For a Fact Sheet on the CY 2021 Physician Fee Schedule proposed rule, please see:

https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-4

For a Fact Sheet on the CY 2021 Hospital Outpatient Prospective Payment System Rule, please see:

https://www.cms.gov/newsroom/fact-sheets/cy-2021-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center

 


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