Radiology could be in store for more code bundling next year, if a proposed 2016 rule issued on July 1 by the U.S. Centers for Medicare and Medicaid Services (CMS) for the Hospital Outpatient Prospective Payment System (HOPPS) is any indication. CMS is proposing to continue its restructuring of Medicare codes, and radiology is among its targets.
CMS has been consolidating and restructuring its ambulatory payment classifications (APCs) in HOPPS. With the July 1 proposal, the agency said it has conducted a comprehensive review of the clinical APCs and that it plans to combine many of them. The end result will be fewer APCs overall for nine clinical APC families:
- Airway endoscopy procedures
- Diagnostic tests and related services
- Excision biopsy and incision and drainage procedures
- Gastrointestinal procedures
- Imaging services
- Orthopedic procedures
- Skin procedures
- Urology and related services procedures
- Vascular procedures (excluding endovascular)
The proposed rule would combine the excision/biopsy and incision and drainage APCs and those for diagnostic radiology (x-ray, CT, MR, and ultrasound) with nuclear imaging.
The consolidation is a major change, according to Pamela Kassing, senior economics and health policy advisor at the American College of Radiology (ACR).
"[The combination of these APCs] is going to require a huge amount of review for the ACR," she told AuntMinnie.com.
Also on the APC side, CMS is proposing APC placement for the soon-to-be-announced CT lung G codes. In preparation for the new Healthcare Common Procedure Coding System (HCPCS) code GXXX2 for low-dose CT scanning for lung cancer screening, CMS is proposing to place the code GXXX2 in APC 5570 (CT without contrast) at a payment rate of $118.15 for the technical component in the hospital outpatient setting, ACR said in a statement.
"The ACR will be considering carefully the APC placement of these codes," the association said.
Conversion factor crunch
A first in this proposed rule is a 2% reduction in the 2016 HOPPS conversion factor, Kassing said. The reduction is meant to counteract approximately $1 billion in inflation in OPPS payments and would result in a $43 million decrease in payments. For hospitals that do not report quality measures, there would be another 2% conversion factor decrease next year, according to Kassing. The 2015 conversion factor is $74.14; in 2016, it would be $73.93, and for hospitals that don't report quality measures, it would be $72.48.
"This is the first time that the HOPPS conversion factor has been reduced," she said. "Usually it is at least a slight increase."
Quality, standards, and cost estimation
The proposed HOPPS rule also includes some changes for quality reporting, payments for the technical component for CT services, and how CMS will calculate costs for CT and MR exams.
Quality reporting. CMS is proposing some adjustments to its hospital outpatient quality reporting program, adding external-beam radiotherapy for bone metastases to its list of measures and removing one imaging-related measure, the use of brain CT in the emergency department for atraumatic headache.
Technical payments for CT. The Protecting Access to Medicare Act of 2014 (PAMA) dictates that for the technical component of applicable CT services paid under the physician fee schedule and HOPPS, a 5% reduction would be implemented in 2016 and a 15% reduction in 2017 -- and subsequent years -- for services provided using equipment that does not meet the requirements of the National Electrical Manufacturers Association (NEMA) Standard XR-29-2013. In this proposed HOPPS rule, CMS plans to establish a new modifier to be used on claims that describes CT services furnished using equipment that does not meet this standard.
Cost estimation models. In 2014, CMS declared it would stop using estimated cost data for CT and MR calculated by square feet -- a formula that divides costs by a service's actual square footage in the hospital -- to determine OPPS rates by 2018. The four-year delay was intended to give hospitals time to transition to a better technique such as the direct allocation method, which calculates specific costs for each piece of equipment, or a dollar value allocation method.
In 2018, CMS will assume that hospitals' data for these exams is not based on the square feet method and will begin setting CT and MR APC relative payment weights using whatever data it receives from providers, the agency said.
Comments, anyone?
As usual, CMS is accepting comments on this proposed rule, taking responses until August 31. It expects to post the final HOPPS rule on November 1.
