Proposed CMS hospital outpatient department rule detrimental for imaging services in CY 2017
October 19, 2016
By Jill Rathbun
With no explanat ion regarding methodology, the Centers for Medicare and Medicaid Services (CMS) proposed another reorganization for payments for imaging services performed in a hospital outpatient department for CY 2017. It is important that hospitals communicate with CMS regarding the negative impact of these proposed changes to daily patient care, given that payments for imaging services were changed for CY 2016 as well.
In short, CMS is proposing to restructure the payments for medical imaging procedures, reducing the total number of payment classifications, or groupings, from 17 to eight. Currently, the imaging procedure payment groupings, known as Ambulatory Payment Classifications (APCs), are based on the imaging technology being used, as well as whether or not contrast media are used. The APCs proposed for implementation in CY 2017 are grouped based on the “level” or geometric mean cost of the image service in question. It is also based on whether or not contrast media are used, yet one of the criteria for an APC is that the services are clinically similar.
The level of proposed cuts in reimbursement for many imaging services will be hard for hospitals to absorb, given that these same rates changed in 2016. Volatility in payment rates from year to year can negatively impact the availability of services. Examples of the magnitude of the proposed cuts are:
• CT and CTA of the pelvis with and without dye (-60%).
• CT Colonography (-44%).
• LDCT lung cancer screening (-44%).
• MRI and MRA with contrast (-39%).
• X-ray and DXA (-37%).
• Ultrasound of the breast, OB, pelvis, transvaginal, fetal (-31%, -24%).
• MRI/MRA without dye (-20%).
One of the requirements of the payment system for hospital outpatient department services is that the services assigned to the same payment amount need to be clinically homogenous. The services in the new proposed APCs are grouped based on cost alone.
It appears that CMS is not aware that imaging modalities are not interchangeable. As an example, an X-ray and an ultrasound that cost roughly the same are not clinically homogenous and are used in the diagnosis of very different conditions. The former often being used for studies of the skeleton, the latter often being used for studies of soft tissue. Yet, CMS has MRI and ultrasound services assigned to the same payment classification as an X-ray service.
It is important for all stakeholders to give input to CMS regarding any proposed payment policy changes prior to their implementation. Given the lack of explanation regarding the methodology for these changes, this opportunity during the recently closed 60-day comment period was challenging. Analysis of the methodology and its expected impacts is a complicated and time-intensive undertaking. It is simply difficult to complete in such a short time period. Therefore, it is important that all those who care about patient access to imaging services in hospital outpatient departments and emergency rooms work together and reach out to CMS to ensure that the payment cuts proposed for 2017 are not implemented.
About the author: Jill Rathbun is managing partner at Galileo Consulting Group.