Redefining Radiopharmaceutical Reimbursement · Learning Objectives ... done or described by another code ... • should notbe disease or indicator specific

© 2016 by the American Pharmacists Association. All rights reserved.

2

Redefining Radiopharmaceutical Reimbursement

Gary Dillehay, MD, FACNM, FACR

Professor of Radiology

Department of Nuclear Medicine

Denise Merlino, MBA, CNMT, CPC

President, Merlino Healthcare Consulting Corp.

3

• Target Audience: Pharmacists

• ACPE#: 0202-0000-16-049-L04-P

• Activity Type: Knowledge-based

4

Learning Objectives

• Discuss current Medicare hospital and physician fee payment policy and rates for radiopharmaceuticals

• List areas where bundling of the radiopharmaceutical and ancillary agents has hidden the true cost of the drug

• Discuss what radiopharmaceutical ASP, AMP, AWP might mean in the overall use and transparency of policy decisions

• Discuss the SNMMI proposal for APC remodeling and how pharmacist can participate

• Discuss the current obstacles for new radiopharmaceutical drug approvals and how this translates to reimbursement and the future of nuclear medicine services

5

Current Future Models for Radiopharmaceutical

Reimbursement

Gary L Dillehay, MD, FACNM, FACR

Professor – Radiology

Nuclear Medicine

Northwestern University Feinberg School of Medicine

Northwestern Memorial Hospital

Chicago, IL

SNMMI Chair – Coding and Reimbursement

6

DisclosuresGary L. Dillehay, MD:

• declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria

The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.


7

Self-Assessment Question 1

Who decides what the final RVU value is for nuclear medicine studies?1

A) AMA

B) AMA CPT Committee

C) AMA RUC Committee

D) CMS

8


How are radiopharmaceuticals currently defined by CMS?

A) drugs

B) supplies

C) devices

D) durable medical equipment (DME)

9


Who is allowed to order radiopharmaceuticals?

A) registered pharmacists

B) certified nuclear medicine technologists

C) licensed physicians

D) authorized users

10


Which of the following is required for reimbursement of a nuclear medicine procedure?

A) formal interpretation (report)

B) signed physician order

C) approved ICD-10 code

D) ALL of these

11

Coding

Coverage

Payment

Reimbursement

Nuclear Medicine Reimbursement

12


Facility vs. Non-FacilityIn-Patient vs. Out-PatientMedicare vs. All Others


13

Physician Fee Schedule

• Medicare uses a fee schedule to determine payment for outpatient Nuclear Medicine services in the non-hospital setting. They are unique to each area (locality) and updated yearly.

• The AMA with medical specialties and the RUC (RVS Update Committee) play a key role in this payment system

14

CODING

Coverage

Payment

Reimbursement


15

CPT

CurrentProceduralTerminology

16

• Medical Services and Procedures • 5 Digit coding system• Modifiers• Nuclear Medicine

– Diagnostic Procedures 78000– Therapy Procedures 79000

CPT

17

How do we get a new CPT code?

• must be a distinct, different service, not already done or described by another code

• currently being performed widely (NOT research)

• statistics (use of 78x99 codes)• literature to support its use

– is it better (or at least as good) than something already available?

18


• should not be disease or indicator specific

• should not be specialty specific

• should not be instrument specific


19


• language must describe exactly what is done

– views, SPECT, W or W/O quantification, contrast

– single, multiple days

20

AMA CPT Editorial Panel

• ALL specialties represented

– Some have permanent seats (Radiology)

– Rotating seats

• other groups also present

– Insurance Industry

– Nursing/Allied Health groups

• political process (can be long)

21

AMA CPT Editorial Panel

• specialty society(s) present new code proposal

• at least 2 members of the panel are assigned new code proposals, but any one on the panel may question presenters

• the panel votes (secret ballot) whether to accept proposal

• proposals for code edits, deletions handled the same way

• political process

22

RUC Process

• RVS (Relative Value Scale)

• Update

• Committee

23

AMA RUC Process

• after the CPT code approved now must have relative work value assigned

• specialty societies survey their members

– anchor code (another CPT code with assigned RVU)

– intensity of work

– stress issues, malpractice issues

– physician time

24

AMA RUC Process

• Practice Expense Review Committee (PERC)

• Practice Expense issues

– non-physician work

– supplies

– equipment


25

Practice Expense MethodologyCMS Goals

• To ensure that the PE payments reflect, to the greatest extent possible, the actual relative resources required for each of the services on the PFS. This could only be accomplished by using the best available data to calculate the PE RVUs.

• To develop a payment system for PE that is understandableand at least somewhat intuitive, so that specialties could generally predict the impacts of changes in the PE data.

• To stabilize the PE payments so that there are not large fluctuations in the payment for given procedures from year-to-year.

26

RBRVS Basic DefinitionsResource Based Relative Value Scale

Calculation of payment based on RBRVS:Work RVU* + PE RVU* + PLI RVU* = RVU

PC = RVUpw+ RVUMD/pe+ RVUMD/mp

TC = RVUoffice/pe+ RVUoffice/mp

Global = PC + TC

Note: Formula above is National information. Each RVU is multiplied by a regional Geographic Practice Cost Index (GPCI) not noted above. There are separate GPCIs for each component, Work, Practice Expense and Malpractice.

Total RVU x $ conversion factor = paymentCF = 2016 Dollar Multiplier $35.8043

* All adjusted for geographic differences

27

2016 Non-Facility Pricing Amount = [(Work RVU * Work GPCI) + (Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor (CF)

2016 Facility Pricing Amount = [(Work RVU * Work GPCI) + (Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor (CF)

Facility vs. Non-Facility

28

Radiology/Nuclear Medicine Reimbursement

• use FDA approved product

• use appropriate CPT code

• with appropriate indication (ICD-10)

REIMBURSED!

29

REIMBURSEMENT

• Physician Report must support what was billed• Provide clinical information (ICD-10)• Describe what was done (CPT)• Describe what was found (Report)• Provide evidence of medical necessity (prn, audit)

30

Nuclear Medicine Report

Indications Hx S&SReferring PhysicianWhat was Done

Radiopharmaceutical and DoseImaging ProcedureAny unusual occurrences

Description of ResultsInterpretationSignature


31

ICD-9-CM

• International• Classification of• Diseases

• Clinical• Modification

32

ICD-10• there are no more codes available in ICD-9 CM

• ICD-10 combines BOTH CPT and diagnosis code into ONE code

• hospitals will probably use first

• NOT controlled by AMA

• a few years off for physicians !!!!!!

33

(International Classification of Diseases)ICD Codes

• Universal diagnosis codes used by all medical specialties used to describe current problem as well as past history, can be linked to coverage, eg. NM, PET/CT studies

• Organized by disease state• Used by CMS to track trends

ICD-9-CM Description ICD-10-CM

793.11 Solitary pulmonary nodule R91.1

793.19 Other nonspecific abnormal finding of lung field

R91.8

794.32 Abnormal EKG R9431

786.59 Other Chest pain R07.89

Intercostal pain R07.82

34

ICD-10-PCS (Procedure Coding System)

• Hospital reporting of inpatient services

• CPT will continue to be used fro physician and outpatient services

• Developed and maintained by CMS

35

Why the Change?ICD-10 provides more specific data than ICD-9

• Better reflects current medical practice

• Structure accommodates addition of new codes• The current coding system is running out of capacity and cannot

accommodate future state of health care

• Expanded data capture• Quality measurement

• Reduce coding errors

• Better analysis of disease patterns

• Track and respond to public health outbreaks

• Make claim submission more efficient

• Identify fraud and abuse

35 36

ICD - Structure

ICD- 9-CM

• 3-5 characters

• First character is numeric or alpha

• (E or V)

• Characters 2-5 are numeric

• Always at least 3 characters

• Use of decimal after 3 characters

• Alpha characters are not case-sensitive

ICD- 10-CM

• 3-7 characters

• Character 1 is alpha

• Character 2 is numeric

• Characters 3-7 are alpha or numeric

• All letters except U

• Always at least 3 characters

• Use of decimal after 3 characters

• Alpha characters are not case-sensitive


37

ICD-10-CM October 1, 2015

38

Major Modifications

• Laterality is used, includes options for left, right, bilateral or unspecified.

– Minimal affect on coding documentation as we already do this.

• New seventh character extension is added to identify the episode of care as initial, subsequent, or sequela.

• Added trimesters to obstetrical & Revised diabetes mellitus

– (5th digits from ICD-9-CM will not be used)

• Expanded codes (e.g., injury, diabetes)

38

39

CMS ICD-10 Web Site

39 40

ICD-10-CM Examples

• V9107XA –burn due to water-skis on fire

41

ICD-10-CM Examples

• W2202XA – hurt walking into a lamppost

42

ICD-10-CM Examples

• Y93D1 – stabbed while crocheting


43

Web Resources ICD -10

www.aapc.com/ICD-10/resources.aspx– Resources for all medical practices solo practitioners-large medical

groups

www.cms.hhs.gov/ICD10

• Complete list of code sets for ICD-10-CM and ICD-10 PCS; final rule and Official ICD-10-CM Guidelines

43 44

Coding

COVERAGE

Payment

Reimbursement


45

Coding Guarantee Payment $$$

46

RADIOPHARMACEUTICALSCoding Issues

“The services listed do not include the radiopharmaceutical or drug. Diagnostic and therapeutic radiopharmaceuticals and drugs supplied by the physician should be reported separately using the appropriate supply code(s), in addition to the procedure code.

47

NUCLEAR MEDICINECoding Issues

Patient does not show up for scheduled procedure and you are left with cost of radiopharmaceutical

– Medicare states that if services are not rendered then you cannot bill. It is the facility choice to decide to bill patient directly, similar to the dentist.

Patient shows up, has radiopharmaceutical and for some reason does not return; or patient gets ill, or claustrophobic, etc

– Bill for procedure with Modifier 52 (reduced service) or Modifier 53 (discontinued service).

– In some locations payer systems can not accommodate modifier 52 and payer may instruct you to code for radiopharmaceutical plus appropriate administration code.

48

RADIOPHARMACEUTICALSCoding Issues

• Every NM Procedure needs at LEAST ONE

• Are BILLED SEPARATELY from the Procedure

• Are coded using HCPCS LEVEL II codes


49

Coding

Coverage

PAYMENT

Reimbursement

50

NUCLEAR MEDICINE ISSUES

• Cost of radiopharmaceuticals

• Availability of agents

• Reimbursement policies

–CMSS

–Private payers

5

51


• AVAILABILTY

–Reimbursement problems

–New agent development issues

552


• REIMBURSEMSNT POLICIES of CMS

– Current HOPPS reimbursement for several outpatient studies do not cover the cost of the radiopharmaceutical

» In-111 Octreotide, I-123 DaTscan

» private payers more liberal

» Patient access issues

5

53


Who decides what the final RVU value is for nuclear medicine studies?1

A) AMA

B) AMA CPT Committee

C) AMA RUC Committee

D) CMS

54


How are radiopharmaceuticals currently defined by CMS?

A) drugs

B) supplies

C) devices

D) durable medical equipment (DME)


55


Who is allowed to order radiopharmaceuticals?

A) registered pharmacists

B) certified nuclear medicine technologists

C) licensed physicians

D) authorized users

56


Which of the following is required for reimbursement of a nuclear medicine procedure?

A) formal interpretation (report)

B) signed physician order

C) approved ICD-10 code

D) ALL of these

57

SNMMI Coding and Reimbursement Activities

• SNMMI Coding and Reimbursement Committee– CPT Advisors to AMA CPT Editorial Committee

– RUC Advisors to AMA Relative Value Update Committee (RUC)

• SNMMI Coding Webinars

• SNMMI Coding Corner

58

59

Current and future models for radiopharmaceutical

reimbursement

Denise A. Merlino, CPC, CNMT, MBA

President, Merlino Healthcare Consulting Corp.

1-19-2016 version

60

Presenter & Disclosures

Denise Merlino, MBA, CNMT, FSNMMI, CPC President, Merlino Healthcare Consulting Corp.

Gloucester, MA

[email protected]

60

Consultant to:SNMMI & ACNM

ASNCBracco

UPPIPharmalucence

American Thoracic Society (ATS)American College of Chest Physicians (CHEST)

American Geriatrics Society (AGS)


61


HOPPS uses _____ data for rate setting?

A) Current

B) One year old

C) Two year old

D) Three year old

62


How often should a provider update their charge masters?

A) Once a month or sooner if prices change

B) Once a quarter or sooner if prices change

C) Once every six months or sooner if prices change

D) Once a year or sooner if prices change

63


What information is needed for appropriate payment in HOPPS?

A) Hospital Claims Data

B) Average Sales Price, at HCPCS level

C) Average Wholesale Price

D) Invoice Costs

64


What are some potential solutions to appropriate payment rates in HOPPS?

A) SNMMI Rp to Procedure Edit Project

B) Education Hospitals – Charge Masters

C) CMS accept ASP for Dx Rp and/or Fix Charge Compression

D) All of the above

65

Topics – Medicare Reimbursement

• Medicare Payment Policy - BASICS

• Status of Medicare Payment Policy– Hospital Outpatient (aka HOPPS)

• Charge Masters - Slow Adoption - Charge Compression

• How to Address HOPPS Payment Policy Issues: – Rp to Procedure Code Edits

– A prospective, proactive solution

65 6666

HospitalInpatient

IPPS/DRG

On Campus-Hospital

OutpatientOPPS/APC

Off Campus-Hospital

OutpatientOPPS/APC

Physician outpatient Services

RBRVS/MPFS

Imaging outpatientCenters (IDTF)

RBRVS/MPFS

POS 21 22 19 11The setting the beneficiary received the technical component (TC) of the service.

Medicare program dollars

Part A Part B

Local Medicare contractors/ administrators of the policies

Fiscal Intermediaries (old) Carriers (old)

Medicare Administrative Contractors (MAC) (Current)

www.cms.hhs.gov/medicarecontractingreform/

Abbreviations: APC, Ambulatory Payment Classifications; DRG, Diagnosis-Related Groups; HOPPS, Hospital Outpatient Prospective Payment System; IPPS, Inpatient Prospective Payment System; MPFS, Medicare Physician Fee Schedule; RBRVS, Resource-Based Relative Value System, POS, Place of Service IDTF, Independent Diagnostic Testing Facilities

POS 15 = Mobile Unit / Facility/ unit that moves from place-to –place equipment to provide diagnostic and or treatment services.

Slide copyright MHCCC 2015


67

MPFS vs HOPPS• MPFS is a system that pays for

covered physicians’ services furnished to a person outside of a hospital.

• Under the MPFS a relative value (RVU) is assigned to each service to capture the direct and indirect (overhead) practice expenses typically involved in furnishing the service.

• The higher the number of relative value units (RVUs) assigned to a service, the higher the payment.

• Radiopharmaceuticals are paid at AWP or invoice cost.

• Drugs are paid at ASP + 6%.

All services under the HOPPS are technical and are classified into groups called Ambulatory Payment Classifications (APCs) groups. Services in each APC are grouped by clinically similar services that require the use of similar resources. A payment rate is established for each APC using two year old hospital claims data adjusted by individual hospital’s cost to charge ratios. The APC national payment rates are adjusted for geographic cost differences with payment rates and policies being updated annually through rulemaking.Currently, diagnostic radiopharmaceuticals are bundled into the APC rate and considered supplies.

68

RP to Procedure Code Edit Project from claims Analysis

68

69

RP to Procedure Code Edit Data HOPPS Claims Analysis

69 70

National Correct Coding InitiativeSNMMI working with NCCI contractor

• SNMMI Letter recommending diagnostic radiopharmaceutical to procedure code edits was sent to NCCI contractor and follow up meeting February/ March 2015.

• NCCI contractor & CMS accepted SNMMI recommended edits:

– NCCI version 21.3 implemented on October 1, 2015. Other societies could have submitted comments by July 1, 2015 if they disagreed with any of the edits, however none did.

70

71

Results from Edit Project

• CMS & the SNMMI have received many inquiries from providers

• SNMMI and the NCCI contractor educated providers on proper coding for diagnostic and therapeutic radiopharmaceuticals.

• Since CMS is using HCPCS codes for bundling payments in APCs, the hope is that by educating the hospitals the CMS hospital claims data will get better.

• This is a long term project, since in HOPPS CMS uses two year old data.

72

2016 - Nuclear Medicine Payment Rates CMS HOPPS APC Restructure

# 2016

APC

CMS Group Title SI Payment

Rate 20161 5591 Level 1 Nuclear Medicine & Related Services

(CPTs 78070-1, 38792, 78195, 78206 liver SPECT / flow, 78264, 78265, GBP studies, Vit- B, 78808, 78445, 78458 bilateral venous thrombosis, 78999)

S $332.65

2 5592 Level 2 Nuclear Medicine & Related Services (CPTs, MRI 75559.SPECT MPI single, parathyroid SPECT/CT, PET limited, blood volume, 78457 venous thrombosis)

S $441.36

3 5593 Level 3 Nuclear Medicine & Related Services (CPTs 75563, 78451-2, 78456, acute venous thrombosis, adrenal 78075, Plat Survival 78191,T codes, brain SPECT, tumor WB, CSF study)

S $1,108.46

4 5594 Level 4 Nuclear Medicine & Related Services (CPTs all PET, CMS reserves the right to put non pet in this APC in the future.)

S $1,285.17

5 5661 Non‐Imaging Nuclear Medicine

(CPTs all therapy, 78725)S $249.98

72

APC rates will vary geographically. Figures used are not actual hospital payment rates.

CPT ® is a registered trademark of the American Medical Association


73

Diagnostic Nuclear Cardiology HOPPS National Rates

Status Description/CPTsHOPPS

2013 Rate

HOPPS 2014 Rate

HOPPS 2015 Rate

HOPPS 2016 Rate

S

Level I Cardiac Imaging

78428, 78466, 78468, 78472, 78473, 78494, 78499

$308.99Incl Dx RP

$383.10Incl Dx RP

$373.42Incl Dx RP

(-2.5%)

Level 1 NM 5591$332.65(-11%)

SLevel II Cardiac Imaging

0331T, 0332T, 78451, 78452, 78454, 78483

$679.68Incl Dx Rp,WM & EF

$1,153.62Incl DX Rp, WM,

EF, 93017, Stress Agent

$1,140.10Incl DX Rp, WM, EF, 93017, Stress Agent

(-1.2%)

Level 3 NM 5593$1,108.46

(-3)

X/Q1Cardiac Stress Test 93017+ $176.82

$244.21 or $0.00

$237.95 or $0.00(-2.6%)

Level 2 Diag. Test 5722$220.35 or $0.00

(-7%)This is the ONLY cardiac stress code which is Technical only. Therefore, it is the only

cardiac stress code used by hospitals on the UB04 claim form.

73


CPT ® is a registered trademark of the American Medical Association 74

Reimbursement Challenges:• Hospital Setting Payment Policy…

– the hospital claims data -“charge compression” is a problem for new or ‘higher cost” tracers.

• Separate payment is not available for established radiopharmaceuticals

• Increased Costs in the Hospital Setting will take minimum of two to three years to be realized in future payments, if not longer.

• Additionally as costs go up, charge compression may contribute to additional under payments for diagnostic radiopharmaceuticals.

74

75

Example: AdreviewTM

APC Packaged RatesCost of RP = Loss to Hospital

75

HCPCS Code DescriptorHOPPS

2013 RateHOPPS

2014 RateHOPPS

2015 RateHOPPS

P 2016 Rate

78075 Adrenal Imaging$955.60 $1,157.42 $1,188.74

$473.78

78804 2 or more day Tumor Imaging $1,172.71

0331T & 0332T

Myocardial sympathetic innervation, imaging, planar qualitative and quantitative assessment; And with tomographic SPECT

$679.68Incl Dx RP,WM & EF

$1,153.62Incl Dx RP, WM,


$1,140.54Incl Dx RP, WM, EF, 93017, Stress Agent

$1,172.71

A9582 Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries Packaged Packaged Packaged Packaged

A9582 RP Cost (ASP Q2 2013)

HOPPS Payment P 2016 Hospital Loss

$2,696.00APC 5593 $1,172.71 (-$1,523.29)

APC 5592 $473.78 (-$2,222.22)



Example AdreviewTM:CMS Data: Cost Versus ASP Plus 6

HCPCS Level II

Total Units

DescriptorMean Cost

Median Cost

Oct 2011 OPPS

Addendum B File

F CY 2011

A95822012 Data

403

Iodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries

$1,331.73 $1,160.71

$2,636.16A9582

2013 Data402 $1,380.34 $1,130.17

A95822014 Data

328 $1,455.44 $1,250.07

76

G.E. (manufacturer of product) ASP Q2 2013 = $2,696.00

ASP+ 6 Pass-Through



77

Diagnostic– Tumor/Distribution of RP AgentHOPPS National Rates

Includes the Diagnostic Radiopharmaceutical(s) & Bundled Ancillary

HCPCS Code

DescriptorHOPPS

2013 RateHOPPS

2014 RateHOPPS

2015 RateHOPPS

2016 Rate

78800Tumor/distribution limited $300.09 $382.77 $377.33 $332.65 (-11%)

78801Tumor/distr., multi area $502.54 $382.77 $377.33 $332.65 (-11%)

78802-3Tumor/dist. WB, single day or Tumor/dist. SPECT

$502.54 $659.97 $706.73 $441.36 (-38%)

78804Tumor/distribution WB, two or more days $955.60 $1,157.42 $1,188.74 $1,108.46 (-7%)

78805-6Tumor/distribution WB, two or more days $502.54 $659.97 $706.73 $1,108.46 (57%)

78999Unlisted Misc, Dx Procedure $114.03 $140.39 $189.16 $332.65 +75.9%

77



Diagnostic– Liver, Hepatobiliary & LymphaticHOPPS National Rates


**C1204 LymphoSeek Oct 2013 - A9520 CY 2014 & 2015 on pass-through per statute off-set applies; CY 2014 offset APC 0400, $61.41, 0392 $71.31. CY 2015 offset 0400, $62.96, 0392 $73.88 CY 2016 Lymphoseek off pass-through status, RP is packaged.

HCPCS Code

DescriptorHOPPS

2013 RateHOPPS

2014 RateHOPPS

2015 RateHOPPS

2016 Rate

78195Lymphatics and lymph node $275.95** $346.34** $369.60** $332.65** (-10%)

78201-78227

All Liver & LS Imaging, Liver SPECT with vascular flow –Hepatobiliary with or without pharm agent

$314.39 $372.57 $373.05 $332.65** (-11%)

38792“Q1”

Status

Inj, proc. Radioactive tracer for ID of sentinel node

$196.59** $257.43** $280.27** $332.65** 19%

78




79

Example: Diagnostic Radiopharmaceutical Off Pass-Through StatusCost of Dx RP will exceed APC packaged payment rate

**C1204 LymphoSeek Oct 2013 - A9520 CY 2014 & 2015 on pass-through per statute off-set applies; CY 2014 offset APC 0400, $61.41, 0392 $71.31. CY 2015 offset 0400, $62.96, 0392 $73.88 CY 2016 Lymphoseek off pass-through status, RP is packaged.

HCPCS Code

DescriptorHOPPS

2014 RateHOPPS

2015 RateHOPPS

P 2016 RateHOPPS

F 2016 Rate

78195 Lymphatics and lymph node $346.34** $369.60**$336.75 (-8.9%)

$332.65 (-10%)

38792“Q1” Status

Inj, proc. Radioactive tracer for ID of sentinel node $257.43** $280.27**

$254.47 (-9.2%)

$332.65(19%)

A9520 Tc99 tilmanocept diag 0.5mci$240.00ASP +6

Jan 1, 2014 rate

$497.00ASP +6

Oct 1, 2015 rate

PackagedOff Pass-through

PackagedOff Pass-through

79

A9520RP Cost (ASP Oct 1, 2015)

HOPPS Payment 2016

Hospital Loss

$497.00 APC 5591 $332.65 (-$164.35)



Diagnostic– GBP, Bone, Lung, Brain & RenalHOPPS National Rates


HCPCS Code

DescriptorHOPPS

2013 RateHOPPS

2014 RateHOPPS

2015 RateHOPPS

2016 Rate

78472 Gated Blood Pool $308.99 $383.10 $373.42 $332.65 (-11%)

78306 Bone whole body $261.68 $323.94 $332.18 $332.65 +0%

78582Lung vent and perfusion

$336.40 $430.87 $440.17 $441.36 +0%

78600Brain Imaging, less than 4

$264.09** $162.68** $176.99** $332.65 +5%

78607 Brain Imaging SPECT $458.34** $1,157.42** $1,188.28** $1,108.46(-7%)

78707Kidney imaging, single w/o pharm agent

$332.91 $417.02 $420.49 $441.36 +5%

**A9584 DatScan packaged for CY 2014-5, off pass-through per statute.

80



81

Example DaTscanTM:CMS Data: Cost Versus ASP Plus 6

© 2010 MEDICAL LEARNING INCORpORATED / SLIDE 8181

HCPCS Level II

Total Units

Descriptor Mean CostMedian

Cost

Oct 2011 OPPS

Addendum B File

F CY 2011

A95842012 Data

4636Iodine I-123 ioflupane, diagnostic, per study dose, up to 5 millicuries

$1,090.13 $930.99

C9406 $1,908.00

A95842013 Data

5774 $1,118.85 $1,012.92

A95842014 Data

4998 $1,119.49 $1,047.84 ASP+ 6 Pass-Through

The cost of this diagnostic radiopharmaceutical (A9582) is a significant cost (CMS definition of >40%) to consider for any APC placement. CMS should consider a policy to address nuclear medicine services that are Radiopharmaceutical cost intense and likely low volume.




Example: DaTscanTM

APC Packaged RatesCost of RP = Loss to Hospital

82**A9584 DaTscanTM packaged for CY 2014-5, off pass-through per statute.


A9584RP Cost (ASP Q4 2013)

HOPPS Payment P 2016 Hospital Loss

$2,380.64

APC 5591 $336.75 (-$2,043.89)

APC 5592 $473.78 (-$1,906.86)

APC 5593 $1,172.71 (-$1,207.93)

HCPCS Code DescriptorHOPPS

2013 RateHOPPS

2014 RateHOPPS

2015 RateHOPPS

P 2016 Rate

78600 Brain Imaging, less than 4 $264.09** $162.68** $176.99** $336.75

78605-6 Brain Imag, min 4–vasc. flow $458.34** $1,157.42** $1,188.28** $473.78

78607 Brain Imaging SPECT $458.34** $1,157.42** $1,188.28** $1,172.71

A9584 Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5 millicuries Packaged Packaged Packaged Packaged



83

Hospital Claim Cost Data 2012 & 2014Used to set 2014 & 2016 Rates

83

Approximately 52 Dx Radiopharm Of those 23 are technetium based

84

Example: Emergency Lung Scan With Tc99m MAA & Tc99m DTPA(Both now single source radiopharmaceuticals)

84

HCPCS Code

DescriptorHOPPS

2013 RateHOPPS

2014 RateHOPPS

2015 RateHOPPS

P 2016 Rate

78582Lung vent and perfusion

$336.40 $430.87 $440.17 $473.78

Increased costs for Dx RP MAAOne vial of MAA is now ~$400 dollars

One dose of MAA is now ~$105 dollars

Increased costs for Dx RP DTPAOne vial of DTPA is now ~$180 dollarsOne dose of DTPA is now ~$60 dollars

Both RPs Required for Procedure Cost

HOPPS Payment P 2016

Hospital Loss

$400 + $180 = $580.00

APC 5592 $473.78 (-$106.22)




85

Diagnostic – Thyroid, Parathyroid & AdrenalHOPPS National Rates




HCPCS Code

DescriptorHOPPS

2013 RateHOPPS

2014 RateHOPPS

2015 RateHOPPS

2016 Rate

78014 Thyroid uptake & scan $232.94 $286.94 $281.89 $332.65 +18%

78070 Parathyroid planar $232.94 $286.94 $281.89 $332.65 +18%

78071 Parathyroid planar & SPECT

$322.04CH APC 0317

$738.69CH APC 0317

$377.18CH APC 0263

$332.65 (-12%)

78072Parathyroid planar & SPECT /CT

$322.04 $738.69 $377.18 $441.36 +17%

78075 Adrenal Imaging $955.60 $1,157.42 $1,188.28 $1,108.46 (-7%)

78195 Lymphatics $275.95** $346.34** $369.60** $332.65** (-10%)

**A9520 Lymphoseek packaged for CY 2016, off pass-through per statute.

85

86

Charge MasterWhen to Update the CDM?

• Minimum Annual Update with Coding Changes– October thru December each year

• Changes in Payer Guidelines or Instructions

• Changes in Technology

• Changes in Pricing

• Department Provides New Services or New Product Lines

• CMS Quarterly Updates (HCPCS & APC) Updates– January, April, July, October

86

87

Dept # Item # Limited Description CPT/HCPC RC PriceActive Code

Deactivation/ Date

302 55486 Tumor SPECT – (Parathyroid) 78803-TC 0341 $3,200.00 N 1/1/2013

302 55450 Parathyroid Imaging (planar) 78070-TC 0341 $1,800.00 Y Modified

302 55490 Parathyroid Planar + SPECT 78071-TC 0341 $3,200.00 Y New

302 55410 Parathyroid Planar + SPECT/CT 78072-TC 0341 $4,200.00 Y New

302 40335 Tc99m pertechnetate, per mCi A9512 0343 $100.00 Y

302 40350 Tc99m sestamibi, PSD A9500 0343 $500.00 Y

Charge Description MasterParathyroid Imaging Effective 1/2013

PSD = per study dosePrice = example to show math and not derived from actual data

TIP: Maintain the tumor SPECT code unless you priced it differently from other tumor imaging. Price for SPECT without CT should be different from SPECT with

CT for attenuation correction (AC) service Watch units for RPs.

87APC rates will vary geographically. Figures used are not actual hospital payment rates.


Basics of a Charge Description Master (CDM) Options for Hospitals to get Costs Right w/ CMS?

• Department # -specific to dept.

• Item # - specific to site

• Short / Limited Description


Deactivation / Date

302 40326 Emer. Add- 99mTc MIBI, PSD A9500 0343 $220.00 Y

302 40331 Emer. Add - 201Thallium, PermCi

A9505 0343 $50.00 Y

302 55424 MPI SPECT Multiple NO WM&EF

78452-TC 0341 $1,500.00 Y

302 55423 MPI SPECT MultipleWM&EF

78452-TC 0341 $2,000.00 Y

302 40325 99mTc MIBI, PSD A9500 0343 $120.00 Y

302 40330 201Thallium, Per mCi A9505 0343 $30.00 Y

302 60235 Inj, regadenoson, per 0.1 mg J2785 0636 $80.00 Y

302 36751 Stress test 93017 0341 $350.00 Y


• CPT/HCPCS Code (previous and new)

• Revenue Code (RC) (hospitals only)

• Price (develop based on your facility costs)

88



89


Deactivation/ Date

302 55486 GES solid 78264-TC 0341 $1,200.00 Y no

302 55450 GES liquid 78264-TC 0341 $1,000.00 Y no

302 55490 GES Solid and Liquid 78264-TC 0341 $1,300.00 Y no

302 55510 GES with small bowel Transit 78265-TC 0341 $2,000.00 Y New

302 55511 GES with SB and Colon Transit 78266-TC 0341 $3,000.00 Y New

302 40350 Tc99m Sulfur colloid, PSD A9541 0343 $300.00 Y No

302 40336 In-111 DTPA A9548 0343 $600.00 Y No

Charge Description MasterGastric Emptying Imaging Study (GES)

Effective 1/2015


TIP: List all the varying protocols and be sure to set price consistent with the workRelated to that particular protocol so that CMS will capture accurate cost data.

89



Issues Identified

• Anecdotal hospital medical practice shifts driven by cost of the Dx RP and HOPPS APC packaged policy

– Decisions on performing PET for FUO (fever of unknown origin), rather than white blood cell (WBC) studies, are being made because of APC cost structure.

– Patients are traveling greater distances for studies as smaller hospitals have stopped performing services that would be at a large cost loss to the hospital.

• Consolidation or industry exiting nuclear medicine field– Some Dx RPs (radiopharmaceuticals) are now single sourced

• – e.g., Technetium MAA, DTPA, Xenon

– Increased costs are not current in CMS HOPPS data due to a two to three year lag

90


91

Consequences

• Burden to beneficiaries who are traveling to the decreasing number of facilities that are performing the low volume high cost NM services.

• Stifles innovation and expansion in the NM community as costs for new diagnostic RPs are not covered after pass-through ends.

91 92

Federal Register Vol. 70 No 141 page 42723 (July 23, 2014)CMS States, “Notwithstanding our commitment to package as many costs as possible, we are aware that packaging payments for certain drugs, biologicals, and radiopharmaceuticals, especially those that are particularly expensive or rarely used, might result in insufficient payments to hospitals, which could adversely affect beneficiary access to medically necessary services.”

92

The SNMMI will presented examples where we believe this is occurring.

93

Diagnostic– Cardiac & Non-Cardiac PET HOPPS National Rates

This is the ONLY cardiac stress code which is Technical only. Therefore, it is the only cardiac stress code used by hospitals on the UB04 claim form.

APC Status Description/CPTsHOPPS

2013 Rate

HOPPS 2014 Rate

HOPPS 2015 Rate

HOPPS 2016 Rate

0308

5594S

Positron Emission Tomography (PET)

78459, 78491, 78492, 78608, 78812, 78813, 78814, 78815, 78816

$1,056.12Incl Dx RP

$1,310.60Incl DX Rp, WM,


(+24%)

$1,285.72Incl DX Rp, WM, EF, 93017, Stress Agent

(-1.9%)

Level 4 NM 5594$1,285.17

(0%)

0100

5722X/Q1

Cardiac Stress Test 93017+ $176.82

$244.21 or $0.00

$237.95 or $0.00(-2.6%)

Level 2 Diag. Test 5722$220.35 or $0.00

(-7 %)

93



SNMMI Proposal CY 2017Nuclear Medicine Dx Rp Grouped APCs

# SNMMI Procedure Group Title

20 RPs remain packaged as under $95 Threshold

SI Simulation CY 2015 FR2013 Mean Unit x

Average unit per day Weighted Average

Sample Dx RPs in the Rps APC Group

1 Level 1 Dx Radiopharmaceutical $95.00 to $200 S $146.17 A9505, A9504, A9500, A9502, A9528, A9580, A9562, A9556,

A9554, A9551

2 Level 2 Dx Radiopharmaceutical $200.01.00 to $400.00 S $226.76 A9552, A9521, C1204/A9520,A9526, A9532, A4642,A9553+

3 Level 3 Dx Radiopharmaceutical $400.01 to $800.00 S $498.66 A9555, A9557, A9569, A9508, A9570, A9548, A9521, A9547

4 Level 4 Dx Radiopharmaceutical $800.01 to $1,200.00 S $951.23 A9542, A9544

5 Level 5 Dx Radiopharmaceutical $1,200.01 to $1,600.00 S $1,396.27 A9507 A9582 (asp avail), A9572

6 Level 6 Dx Radiopharmaceutical $1,600.01 to $2,000.00 S None this year

7 Level 7 Dx Radiopharmaceutical $2,000.01 to $2,400.00 S $2,380.64 A9584 DatScan

8 Level 8 Dx Radiopharmaceutical $2,400.01 to $2,800.00 S $2,696.00 A9582 I-123 MIBG & A9568 B-Amyloid

9 Level 9 Dx Radiopharmaceutical $2,800.01 to $3,200.00 S None this year

10 Level 10 Dx Radiopharmaceutical $3,200.01 to greater S None this year

94

95

SNMMI Request to CMS

• It is critical to the success of a reconfiguration of the nuclear medicine APC group, the SNMMI requests that CMS reconsider and propose for public comment period to implement APCs for groups of diagnostic radiopharmaceuticals that will be paid separately from the nuclear medicine APC procedure groups for CY 2017.

95 96

Therapeutic Nuclear Medicine ServicesHOPPS National Rates Does NOT include Therapeutic Rp(s)

APC 0413 Eliminated All Rp Therapy in APC 0407 CY 2015Non-Imaging NM APC 5661 mixes Therapy & Non Imaging Studies

HCPCS Code

DescriptorHOPPS

2013 RateHOPPS

2014 RateHOPPS

2015 RateHOPPS

2016 Rate

79005 Radiopharm. Therapy, oral $236.71 $255.81

$276.93$249.98

(-10%)

79101 Radiopharm. Therapy, I.V. $236.71 $255.81

79200 Radiopharm. Therapy, I.C. $301.01 $356.68

79300 Rp. Therapy, I.S. Colloid $236.71 $255.81

79403 Rp Therapy, IV infusion antibody $301.01 $356.68

79440 Radiopharm. Therapy, I.A. $301.01 $356.68

79445 Rp Therapy, I.A. particulate $236.71 $255.81

79999 Radiopharm. Therapy, U.P. $236.71 $255.81

78725Kidney function study, non-imaging radioisotopic study $196.59 $257.43 $280.27 $249.98 (-11%)

96




97


HOPPS uses _____ data for rate setting?

A) Current

B) One year old

C) Two year old

D) Three year old

98


What is the minimum timing for a provider updating the charge master with new codes and payment rates?

A) Once a month or sooner if prices change

B) Once a quarter or sooner if prices change

C) Once every six months or sooner if prices change

D) Once a year or sooner if prices change

99


What information is needed for appropriate payment in HOPPS?

A) Hospital Claims Data

B) Average Sales Price, at HCPCS level

C) Average Wholesale Price

D) Invoice Costs

100


What are some potential solutions to appropriate payment rates in HOPPS?

A) SNMMI Rp to Procedure Edit Project

B) Education Hospitals – Charge Masters

C) CMS accept ASP for Dx Rp or Fix Charge Compression

D) All of the above

101

QUESTIONS?

Documents

Redefining Radiopharmaceutical Reimbursement · Learning Objectives ... done or described by another code ... • should notbe disease or indicator specific