Centers for Medicare and Medicaid Services (CMS) Posted Final 2020 Payment Rules

Late Friday, November 1, the Centers for Medicare and Medicaid Services (CMS) posted the final 2020 payment rules for the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (OPPS).  These rules contain proposed policy and payment changes under the Medicare program.  

The OPPS rule governs technical component (TC) reimbursement for medical services provided in the hospital outpatient setting. Technical component reimbursement is intended to reflect the non-physician costs of the procedure. Under the OPPS, CMS assigns each individual medical service 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 has grouped clinically dissimilar services together in APCs.  This has resulted in a marked and significant decline in technical component reimbursement for many imaging services, including CMR codes.

SCMR submitted comments to CMS to express concerns about APC placement and to set forth a justification for moving CMR codes to other APCs that contain services that are more clinically similar.  CMS rejected the arguments.  SCMR plans to follow up with CMS early in 2020 to further discuss how CMS views the concept of clinical homogeneity.

Once again, we are faced with reductions in OPPS reimbursement for most codes except CPT 75557.  To improve reimbursement under the OPPS, facilities must 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 claims data that reflects the true cost of providing CMR services, reimbursement may continue to decline.

In the text of the final 2020 hospital outpatient rule, CMS noted in part:

            ‘with regard to the issue of different hospital cost reporting methods, we are unable to determine whether hospitals are misreporting the procedure. It is generally not our policy to judge the accuracy of hospital charging and coding for purposes of ratesetting.  We rely on hospitals to accurately report the use of HCPCS codes in accordance with their code descriptors and CPT and CMS instructions, and to appropriately report services on claims and charges and costs for the services on their Medicare hospital cost report.  Also, we do not specify the methodologies that hospitals use to set charges for this or any other service.  Furthermore, we state in Chapter 4 of the Medicare Claims Processing Manual that “it is extremely important that hospitals report all HCPCS codes consistent with their descriptors; CPT and/or CMS instructions and correct coding principles, and all charges for all services they furnish, whether payment for the services is made separately paid or is packaged” to enable CMS to establish future ratesetting for OPPS services.’

SCMR will continue to examine CMS cost center policies and how hospital cost to charge ratios affect CMR reimbursement.  The SCMR has also taken active steps by hiring a consultant to analyze current hospital charging practices so that a road map can be created to combat the low reimbursement. We recognize that continued reductions are unsustainable and jeopardize the availability of cardiac MR services.

Below is a chart with final rule payment amounts for the CMR codes. Note that both the Medicare Physician Fee Schedule and Hospital Outpatient Prospective Payment System payments are reflected.  The MPFS contains the professional component (PC) payment (physician payment). It also contains the TC payment for imaging services provided in the physician office setting. Payment for the TC provided in the office setting is capped at the lesser payment amount of that provided under MPFS or OPPS.

75557 CMR w/o contrast w/out stress$335.88 TC $217.44 PC $118.44$330.12 TC $211.55 PC $118.57$325.17 TC $206.79 PC $118.38$245.22 APC 5523$230.56 APC 5523$233.01 APC 5523
75559 CMR w stress w/o contrast$453.24 TC $307.08 PC $146.16$460.22 TC $314.26 PC $145.96$451.48 TC $306.03 PC $145.45$245.22 APC 5523$497.49 APC 5524$481.53 APC 5524
75561 CMR resting w w/o contrast$442.44 TC $311.76 PC $130.68$433.55 TC $302.73 PC $130.82$426.58 TC $296.30 PC $130.28$456.34 APC 5572$385.88 APC 5572$381.81 APC 5572
75563 CMR w stress w contrast$526.31 TC $376.19 PC $150.12$513.92 TC $364.00 PC $149.92$505.25 TC $354.76 PC $150.49$681.83 APC 5573$691.75 APC 5573$680.74 APC 5573

SCMR will continue to review both rules for provisions of interest to the imaging community. You may view the proposed rules and CMS Fact Sheets at:

Newsbeat Banner

SCMR Newsletter brought to you by NewsBeat

Read the current SCMR NewsBeat to stay up to date with the latest SCMR News!