Government Relations
GR News
November 13, 2008
CMS Announces Final Changes to Policies & Payments For Hospital Outpatient Services (HOPPS) Effective CY January 1, 2009
CMS Final Rule
On October 30, 2008, the Centers for Medicare & Medicaid Services (CMS) posted a final rule for Medicare payment for hospital outpatient services and ambulatory surgical centers for calendar year (CY) 2009. The final rules affect hospital outpatient and ASC payments for services paid under the outpatient prospective payment (HOPPS) and ASC systems. The final rule includes a 3.6 percent annual inflation update to Medicare payment rates for most services that would be paid under the OPPS. However, this percent increase was not realized for all procedures important to our community; (see attached SNM chart and below table). The final rule looks much like the proposed rule with minor changes to payment rates as noted in this summary. Important Nuclear Medicine, Nuclear Cardiology and Cardiac CTA final 2009 CMS HOPPS policies include:
- CMS continues packaging payments for ALL diagnostic radiopharmaceuticals and contrast agents in with the APC category (major service procedure). CMS will continue to use hospital claims data median costs, as derived from hospital charges reduced by department specific Cost to Charge Ratios (CCR) for rate setting in 2009.
- CMS is extending for one more year the 2008 rate setting methodology for diagnostic nuclear medicine APCs in 2009, using only claims that include a charge with a required diagnostic, therapeutic or other radioactive product.
- For (new) transitional pass-through diagnostic radiopharmaceuticals (RP) payments, CMS stated in the rule, "they will use the device methodology to estimate radiopharmaceutical offset costs that could reasonably be attributed to the diagnostic RP packaged into APC groups in an effort to avoid duplicate payments.
- The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) was enacted on July 15, 2008 mandating CMS’s continuation of therapeutic radiopharmaceuticals and brachytherapy sources paid at individual hospital (overall) Cost to Charge (CCR) times the individual hospital charges for rate setting, through December 31, 2009. CMS was pleased that nuclear medicine stakeholders were interested in an ASP methodology for therapeutic radiopharmaceuticals, however this law is clear and leaves no opportunity for 2009.
- Drugs and biologicals are finalized to be paid at 104 percent of the average sales price (ASP+4). As a reminder the office and IDTF settings current rate is 106 percent of average sales price (ASP).
- CMS finalizes separate payment for drugs, biologicals and therapeutic radiopharmaceuticals costing $60 or more per day. Payments for other drugs will continue to be bundled into payments for their associated procedures.
- CMS continues packaging add-on "image processing services" with the costs of the major procedure CPT codes. Examples of packaged CPT codes are, 76376, 76377, 78020, 78478, 78480 and 78496.
The SNM prepares charts and spreadsheets that evaluate the impact of the Final HOPPS rule for nuclear medicine procedures and products. The materials are available online via the SNM Coding Corner.
The Final 2009 HOPPS Rule can be found on the CMS website:
The rule was placed on the CMS website on October 30, 2008 and will be published in the Federal Register on November 18th. It is effective for outpatient and ASC services furnished to Medicare beneficiaries on or after January 1, 2009.
