From the December 2015 issue of HealthCare Business News magazine

Another important area in the MPF rule for imaging was the list of procedures that had been identified and proposed for review as “misvalued” services. CMS finalized 103 of the 110 proposed “high expenditure” codes for review. Among the codes that were removed were two ultrasound codes and one nuclear medicine code, leaving 26 remaining imaging codes on the final list. The majority of these 26 codes are MRI and X-ray procedures.

For these 26 procedures, CMS will begin misvalued code reviews, with changes to Relative Value Units proposed as early as next year’s — 2017 — MPFS proposed rule. Regarding the Hospital Outpatient Department Prospective Payment System, CMS finalized its proposal to restructure the Ambulatory Payment Classifications (APCs) for imaging services, reducing the number of imaging APCs from 54 to 25. This means that the payments are less granular and less specific to an individual procedure’s costs.


In finalizing this proposal, CMS did make one structural change by adding one additional APC for nuclear medicine, in order to separate Positron Emission Tomography (PET) services from other services in other APCs. CMS also agreed to move 38 out of 114 commenter-requested individual codes (many Xray and ultrasound) from one APC to another.

To understand the effect of this APC grouping change, a hospital outpatient department needs to look at the new payments assigned to the imaging procedures that they perform and determine the volume of each procedure in a single year. This would allow a hospital outpatient department to understand the impact of this proposal to its overall Medicare revenue — do the procedures that are “winners” offset those that are experiencing reductions in payments for CY 2016? To read more about the Final 2016 Medicare Fee Schedule Rules and to check the addendum for payment amounts for individual imaging procedures, please visit the following CMS Web sites:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Physician-FeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1631-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html
About the author:Jill Rathbun is managing partner at Galileo Consulting Group in Arlington, Virginia. Shewill be commenting for HealthCare Business News on issues of interest to health care professionals.

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December 2015 Magazine

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