Jill Rathbun

View from the Hill - CMS rule to cut payments

August 21, 2015
On July 1, 2015, the Centers for Medicare and Medicaid Services (CMS) released their proposed rule for CY 2016 for Hospital Outpatient Departments (OPPS) and Ambulatory Surgical Centers Prospective Payment Systems.

With this proposed rule, CMS projects total OPPS payments to decrease by 0.1 percent in CY 2016. The proposed decrease in payment rates is based on adjustments to the payment update to redress the excessive packaging of services in 2014, particular lab services, and other policy changes as required by law.

After considering all other policy changes proposed under the OPPS, including estimated spending for pass-through payments, CMS estimates that total payments for the approximately 3,800 hospitals and 60 CMHCs paid under the OPPS would decrease by $43 million in CY 2016 compared to CY 2015 payments.

Also, hospitals failing to meet the hospital outpatient quality reporting program in 2014 would be subject to a 2 percent reduction on their 2016 payments. Comments will be accepted by CMS on this proposed rule if submitted by Aug. 31, 2015. This proposed rule is of interest to the imaging community for several reasons.

First, it proposes a re-organization of the Ambulatory Payment Classifications (APCs) for imaging services that reduces the overall number of payment categories. For some services this means large increases, and it also means, for others, fairly large decreases. Depending on what imaging services your hospital outpatient department focuses on, this could be a winning proposal or it could be of concern.

The 60-day comment period gives all stakeholders the opportunity to evaluate the proposed reconfiguration and decide if there are better ways to do what CMS is attempting, and send that in to CMS. In proposing an APC reconfiguration for hospital outpatient department payments for imaging services, CMS states that the current level of granularity in some of the imaging APCs is unnecessarily narrow for the purposes of a prospective payment system.

CMS specifically called out the current APCs for X-ray and nuclear medicine services as supporting this rationale. Therefore, CMS is proposing to consolidate the APCs for radiology and nuclear medicine services, with the proposed new APCs only being differentiated by type of modality and whether or not contrast was used during the imaging procedure.

The resources used to perform the procedure, as represented by hospital submitted claims data, would be used to determine what level of APC the procedure would be assigned to. Another area that was of concern to the imaging community last year was the expanded “packaging or bundling” proposal that CMS finalized, whereby certain imaging APCs, where the geometric mean for the APC was less than $100, would be packaged or not pay separately when those services were performed with a surgical procedure on the same day.

There was concern that CMS would expand this proposal for CY 2016 and then more imaging services would not be paid separately, making the OPPS payment system almost exclusively like the inpatient/MS-DRG payment system where imaging services are included in the MS-DRG payment. While CMS did expand their packaging proposal to three additional APCs, two were for lab services and one was for minor procedures.

This is a good outcome for the imaging community. CMS also discusses in this proposed rule the continued use of Composite APCs to pay one amount when two or more imaging services of the same modality and family are performed on the same day for the same patient. CMS talks about only using claims to set the rate of the Composite APC that are claims with two or more imaging services and the process for cleaning and analyzing that data.

Finally, CMS proposes the process that hospital outpatient departments will have to use to verify that their CT machines meet the MITA low-dose CT standard, so that those studies do not have their payments reduced starting in 2016. CMS proposes that hospitals use a modifier on their CT claims to attest that their CT machines meet the standards.

About the author: Jill Rathbun is managing partner at Galileo Consulting Group, in Arlington, VA. She will be commenting for DOTmed HealthCare Business News on issues of interest to health care professionals.