2016 HOPPS and Physician Fee Schedule (PFS

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2016 Medicare Update NMD Healthcare Consulting © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL…
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2016 Medicare Update NMD Healthcare Consulting © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. Presenter Rudy Karin Director, Reimbursement Strategy NMD Healthcare Consulting 2 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. Agenda ã NM & PET Code Changes for CY 2016 – CPT & HCPCS Level II codes ã Hospital Outpatient Prospective Payment System (HOPPS) – Background – Policy Changes – Payment Rates ã Physician Fee Schedule (MPFS) – Background – Repeal of SGR & impact on CF – Policy Changes – Procedure Reimbursement ã Q&A 3 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. NM & PET CODE CHANGES CY 2016 4 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. New & Revised CPT Codes CY 2016 CPT Code Long Descriptor ▲78264 Gastric Emptying Imaging Study (eg, solid, liquid or both); Gastric Emptying Imaging Study (eg, solid, liquid or both); ●78265 with small bowel transit Gastric Emptying Imaging Study (eg, solid, liquid or both); ●78266 with small bowel and colon transit, multiple days (Report 78264, 78265, or 78266 only once per imaging study) 5 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. New HCPCS Level II Codes CY 2016 HCPCS 1Q 2016 Rate Level II APC Description SI FINAL Code (Proposed) Florbetaben F-18, diagnostic, per study dose, up to 8.1 millicuries C9458 9458 G $2,968.00 (Trade Name: Neuraceq; Mfr’d by Piramal; NDC# 54828-0001-30 (30 ml vial)) Flutemetamol F-18, diagnostic, per study dose, up to 5 millicuries C9459 9459 G $3,135.00 (Trade Name: Vizamyl; Mfr’d by G.E.; 17156- 0067-10 (10 ml vial) or 17156-0067-30 (30 ml vial)) Note: HCPCS Level II “C” codes can only be used in the hospital outpatient department provider setting. Use A9599 – Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (PET imaging, per study dose for studies performed in the free-standing clinic/Independent Diagnostic Testing Facility (IDTF) 6 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. HOSPITAL OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (HOPPS) – 2016 7 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. Hospital Outpatient Prospective Payment System (HOPPS) ã Payments to Hospitals ã In a prospective payment system, the payer sets: – Amount it will pay for services – Services included in the payment amount (packaging) – Rate of change in payments over time ã In the hospital setting, CMS considers diagnostic radiopharmaceuticals (RP) supplies – RP payment is packaged in the procedure payment ã Payment rates based on Ambulatory Payment Classifications or APCs 8 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. What are APCs? ã Medicare assigns payable CPT procedure and HCPCS codes with similar resources to a given APC – CPT® = Current Procedural Terminology assigned by the American Medical Association (AMA) ã 5-digit numeric codes to describe a procedure – HCPCS = Healthcare Common Procedure Coding System ã 5-digit alpha-numeric code used for radiopharmaceuticals and drugs in nuclear medicine ã Payment rate is assigned to the APC and any CPT mapped to that particular APC will be paid at the same rate, with geographic fluctuation CPT copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association 9 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. Payment Methodology In simple terms: ã Rate is based on Medicare claims data from two years prior (e.g., 2016 rate is determined by 2014 claims) – Because the radiopharmaceuticals assigned to the procedures in each APC can be widely varying in cost, we often see underpayments for low volume/high cost procedures ã APC Payment Rate = - Weighted Avg. (TC charges) + Weighted Avg. (RP charges) – Cost-based relative payment weights using geometric mean costs ã Geometric mean is generally ≤ arithmetic mean ã Better assessment of data when large variations 10 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. HOPPS Executive summary ã Dx RP Reimbursement Continue packaged ã 23 nuclear medicine APCs down to 5 APCs – Consolidation results in mixed rate changes, impacts Pkg’d expensive Dx RPs ã SPECT MPI procedure payments will slightly decline ã $10 per dose payment for non HEU Tc-99m ã PET procedures are in the same APC (APC 5594 Level 4). Reimbursement is flat ã Lymphoseek® Pass-Through Status expired ã Xofigo – Separate Pmt for Tx RPs; ASP +6%; remains unchanged ã Amyvid – Pass Through Status continues; to be paid at ASP +6% or WAC+6%; remains unchanged ã Neuraceq and Vizamyl – New Pass-Through Status effective 1Q 2016 ã Dx RP edit ended; but you still need to put it on the claim 11 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. 2016 HOPPS – Policies Continued What did NOT change? ã Pass-Through Status (SI “G”) for 1 Dx RP Continues: – Amyvid, HCPCS A9606 (Eff 1/1/2015; continues 2nd Yr.) – Reimbursement remains at ASP+6% or WAC+6% ã Diagnostic Radiopharmaceuticals (w/o Pass-Through Status “N”) – Packaged into APC Procedure Payment – APC Offset represents Dx RP portion of APC Procedure Rate ã Separate payment for therapeutic RPs & Separately Paid Drugs (Si “K”) – Either ASP+6% or WAC+6% ã Non-HEU add-on payment policy for Tc-99m based RP which are derived from at least 95% non-HEU sources and priced based on the Full Cost Recovery Method – HCPCS code Q9969; APC 1442 (non-HEU Tc-99m Add-on/Dose) – Payment rate $10; 20% patient co-pay ($2) ã Composite APCs - Multiple Imaging remains unchanged ã Sequestration 2% Reduction Continues ã Coding Edits for RPs – Not Reinstated 12 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. 2016 HOPPS Policies – New/Revised ã Overall HOPPS Payments estimated to decrease by (- 0.4%) – (-0.3%) Conversion Factor Update (2.4% Market Basket minus Adj) ã $73.725 – Hospitals that meet Quality Reporting Requirements ã $72.251 – Hospitals failed to meet Quality Reporting Requirements – Other policy changes incl. estimated spending for Pass-Through Pmts ã New Nuclear Medicine APC Consolidation & Restructuring ã Transitional Pass-Through Status – Lymphoseek Pass-Through Ended Dec. 31st, 2015 – New Pass-Through Status for 2 Amyloid AD Imaging Agents ã Threshold for Packaged Drugs & Tx RPs @ $100/day ã New Status and Comment Indicators (“J2”, “Q4”, “NP”) ã HOPPS Payment Rate Changes 13 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. NM & PET APC Restructuring and Consolidation ã 23 Nuclear Medicine APCs consolidated into 5 APCs (FINAL) – 4 APCs Proposed ã NM Imaging & Non-Imaging restructuring finalized: – Level I – NM & Related Services; APC 5591 ($332.65) – Level 2 – NM & Related Services; APC 5592 ($441.36) – Level 3 – NM & Related Services; APC 5593 ($1,108.46) – Level 4 – NM & Related Services; APC 5594 ($1,285.17) ã PET now assigned to Level 4 (originally Level 3 with MPI & others) – Therapeutic NM; APC 5661 ($249.98) ã Proposed – Non-Imaging Nuclear Medicine (Including CPT 38792) ã FINAL Only Therapy ã RP therapy administration (Oral & IV) Codes 14 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. HOPPS NM APC Restructuring – CY 2016 FINAL 1Q 2016 Rate APC APC Descriptor – FINAL Assignments SI FINAL Level 1 Nuclear Medicine & Related 5591 S $332.65 Services Level 2 Nuclear Medicine & Related 5592 S $441.36 Services Level 3 Nuclear Medicine & Related 5593 S $1,108.46 Services Level 4 Nuclear Medicine & Related 5594 S $1,285.17 Services Therapeutic (Non-Imaging) Nuclear 5661 S $249.98 Medicine 15 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. NM & PET APC Restructuring and Consolidation ã Impact: – Consolidation from 23 to 5 APCs will only exacerbate the problem of high cost, under reimbursed radiopharmaceuticals – CMS believes “that the current APC structure is based on clinical categories that do not necessarily reflect significant differences in the delivery of these services in the hospital outpatient department” and the existing “APCs result in groupings that are unnecessarily narrow for a PPS”. – These new Proposed APC configurations, according to CMS, are based upon the cost of delivery of these services. – SPECT MPI and MI PET were kept in different APCs ã SPECT MPI = $1,140.54 (4Q 15) vs $1,108.46 (1Q 16) ã MI PET = $1,286.23 (4Q 15) vs $1,285.17 (1Q 16) 16 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. NM HOPPS Policy Changes - Lymphoseek ã Lymphoseek Transitional Pass-Through Status ended December 31, 2015. – Reimbursement for A9520 will be packaged into the APC Procedure payments ã CPT 38792 (APC 5591) 1Q 2016 Rate = $332.65 ã CPT 78195 (APC 5591) 1Q 2016 Rate = $332.65 17 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. Nuclear Cardiology MPI – APC & Rate Changes CPT APC HOPPS Rate % Code Descriptor Change 2015 2016 4Q 2015 1Q 2016 MPI, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection 78451 fraction by first pass or gated technique, additional 0377 5593 $1,140.54 $1,108.46 -2.8% quantification, when performed); single study, at rest or stress (exercise or pharmacologic) MPI, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional 78452 quantification, when performed); multiple studies, at rest 0377 5593 $1,140.54 $1,108.46 -2.8% and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection MPI, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, 78453 additional quantification, when performed); single study, at 0377 5592 $1,140.54 $441.36 -61.3% rest or stress (exercise or pharmacologic) MPI, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, 78454 additional quantification, when performed); multiple 0377 5593 $1,140.54 $1,108.46 -2.8% studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection Cardiovascular stress test using maximal or submaximal Pkg’d or Pkg’d or treadmill or bicycle exercise, continuous 93017 electrocardiographic monitoring, and/or pharmacological 0100 5722 $238.04 $220.35 -7.4% stress; tracing only, without interpretation and report (Q1) (Q1) Note: Q1 – Conditionally packaged; packaged APC payment if billed on the same DOS as a HCPCS code w SI “S”, “T”, or “V”. Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment 18 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. MPI Packaging – Continues ã Effective January 1, 2014; Continued CY 2016 ã Packaging the stress portion & stress agent with payment for MPI when performed together in the hospital setting Payment Rates 4Q 2013 4Q 2014 4Q 2015 1Q 2016 Stress Type Exercise Dipyridamoze Lexiscan Adenosine Any type Any type Any type 78452 $679.68 $679.68 $679.68 $679.68 $1153.62 $1,140.54 $1,108.46 93017 $176.82 $176.82 $176.82 $176.82 Pkg’d Pkg’d Pkg’d $213.72 $218.76 Stress Rx Included Pkg’d Pkg’d Pkg’d Pkg’d (0.4mg) (60mg) RP Pkg’d Pkg’d Pkg’d Pkg’d Pkg’d Pkg’d Pkg’d Total $856.50 $856.50 $1070.22 $1075.26 $1153.62 $1,140.54 $1,108.46 19 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. Cardiovascular PET – APC & Rate Changes APC HOPPS Rate CPT % Code Descriptor Change 2015 2016 4Q 2015 1Q 2016 Myocardial imaging, positron emission tomography 78459 (PET), metabolic evaluation 0308 5594 $1,286.23 $1,285.17 -0.1% Myocardial imaging, positron emission tomography 78491 (PET), perfusion; single study at rest or stress 0308 5594 $1,286.23 $1,285.17 -0.1% Myocardial imaging, positron emission tomography 78492 (PET), perfusion; multiple studies at rest and/or stress 0308 5594 $1,286.23 $1,285.17 -0.1% Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous Pkg’d or Pkg’d or 93017 electrocardiographic monitoring, and/or pharmacological 0100 5722 $238.04 $220.35 -7.4% stress; tracing only, without interpretation and report (Q1) (Q1) Note: ã Q1 – Conditionally packaged; packaged APC payment if billed on the same DOS as a HCPCS code w SI “S”, “T”, or “V” ã Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment 20 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. Cardiovascular System – APC & Rate Changes CPT APC HOPPS Rate % Code Descriptor Change 2015 2016 4Q 2015 1Q 2016 Myocardial sympathetic innervation imaging, planar 0331T qualitative and quantitative assessment; 0377 5593 $1,140.54 $1,108.46 -2.8% Myocardial sympathetic innervation imaging, planar 0332T qualitative and quantitative assessment; with 0377 5593 $1,140.54 $1,108.46 -2.8% tomographic SPECT 78428 Cardiac shunt detection 0398 5591 $373.56 $332.65 -11.0% Non-cardiac vascular flow imaging (ie, angiography, 78445 venography) 0263 5523 $337.03 $332.65 -1.3% 78456 Acute venous thrombosis imaging, peptide 0317 5593 $813.20 $1,108.46 +36.3% 78457 Venous thrombosis imaging, venogram; unilateral 0263 5592 $337.03 $441.36 +31.0% 78458 Venous thrombosis imaging, venogram; bilateral 0263 5591 $337.03 $332.65 -1.3% Myocardial imaging, infarct avid, planar; qualitative 78466 or quantitative 0398 5591 $373.56 $332.65 -11.0% Myocardial imaging, infarct avid, planar; with 78468 ejection fraction by first pass technique 0398 5591 $373.56 $332.65 -11.0% Myocardial imaging, infarct avid, planar; 78469 tomographic SPECT with or without quantification 0398 5592 $373.56 $441.36 +18.1% Note: Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment 21 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. MUGA Studies – APC & Rate Changes APC HOPPS Rate CPT % Code Descriptor Change 2015 2016 4Q 2015 1Q 2016 Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or 78472 pharmacologic), wall motion study plus ejection fraction, 0398 5591 $373.56 $332.65 -11.0% with or without additional quantitative processing Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest 78473 and stress (exercise and/or pharmacologic), with or 0398 5591 $373.56 $332.65 -11.0% without additional quantification Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise 78481 and/or pharmacologic), wall motion study plus ejection 0398 5592 $373.56 $441.36 +18.1% fraction, with or without quantification Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress 78483 (exercise and/or pharmacologic), wall motion study plus 0377 5592 $1,140.54 $441.36 -61.3% ejection fraction, with or without quantification Cardiac blood pool imaging, gated equilibrium, SPECT, 78494 at rest, wall motion study plus ejection fraction, with or 0398 5591 $373.56 332.65 -11.0% without quantitative processing Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by Pkg’d Pkg’d +78496 NA NA NA first pass technique (List separately in addition to code (“N”) (“N”) for primary procedure) Note: Dx RPs & Pharmacologic Stress Agents Status Indicator “N”; Packaged into APC Procedure Payment 22 © Copyright 2016, Cardinal Health. All rights reserved. CARDINAL HEALTH, the Cardinal Health LOGO and ESSENTIAL TO CARE are trademarks or registered trademarks of Cardinal Health. All other marks are the property of their respective owners. Non Cardiac PET – APC & Rate Changes APC HOPPS Rate CPT % Code Descriptor Change 2015 2016 4Q 2015 1Q 2016 78608 Brain imaging, PET; metabolic evaluation 0308 5594 $1,286.23 $1,285.17 -0.1% 78811 PET imaging; limited area (eg, chest, head/neck) 0308 5594 $1,286.23 $1,285.17 -0.1% 78812 PET imaging; skull base to mid-thigh 0308 5594 $1,286.23 $1,285.17 -0.1% 78813 PET imaging; whole body 0308 5594 $1,286.23 $1,285.17 -0.1% PET with concurrently acquired computed tomography (CT) for attenuation correction and 78814 anatomical localization imaging; limited area (eg, 0308 5594 $1,286.23 $1,285.17 -0.1% chest, head/neck) PET wit
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