The OPPS rule governs technical component 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 (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 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.
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 will continue to decline. SCMR will continue to engage CMS about appropriate APC assignment for CMR services and explore data modeling to identify more appropriate placement for CMR codes.
Below is an imaging chart with associated reimbursement impacts for the CMR codes, under both the OPPS and MPFS proposed rules. SCMR will continue its analysis and provide comments to CMS by the September 27, 2019 deadline.
| CPT Codes | 2018 MPFS PC/TC FINAL | 2019 MPFS PC/TC FINAL | 2020 Proposed MFPS PC/TC | 2018 OPPS TC FINAL | 2019 OPPS TC FINAL | 2020 Proposed OPPS TC |
| 75557 CMR w/o contrast w/out stress | $335.88 TC $217.44 PC $118.44 | $330.12 TC $211.55 PC $118.57 | $323.72 TC $205.35 PC $118.37 | $245.22 APC 5523 | $230.56 APC 5523 | $231.28 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 | $449.32 TC $303.88 PC $145.44 | $245.22 APC 5523 | $497.49 APC 5524 | $474.44 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 | $425.50 TC $294.49 PC $131.01 | $456.34 APC 5572 | $385.88 APC 5572 | $373.45 APC 5572 |
| 75563 CMR w stress w contrast | $526.31 TC $376.19 PC $150.12 | $513.92 TC $364.00 PC $149.92 | $502.73 TC $352.60 PC $150.13 | $681.83 APC 5573 | $691.75 APC 5573 | $682.96 APC 5573 |
A CMS Fact Sheet on the overall provisions of the proposed MPFS rule is available at:
A CMS Fact Sheet on the overall provisions of the proposed OPPS rule is available at:
