Improving Health Through Medical Physics

AAPM Newsletter — Volume 42 No.5 — September|October 2017

HEALTH POLICY & ECONOMIC ISSUES Wendy Smith Fuss, MPH, AAPM Health Policy Consultant

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CMS Proposes "Correctly Coded" Comprehensive APCs for Brachytherapy Insertion Codes

The Centers for Medicare and Medicaid Services (CMS) recently released the 2018 Hospital Outpatient Prospective Payment System (HOPPS) proposed rule, which provides facility payments to hospital outpatient departments. AAPM will submit comments to CMS by the September 11 deadline. The final rule will be published by November 1, with an effective date of January 1, 2018. Payments to physicians and freestanding cancer centers is described in a separate article below.

CMS proposes to eliminate the Low Dose Rate Prostate Brachytherapy Composite ambulatory payment classification (APC) for CPT 55875 + 77778 billed on the same day and instead assign CPT 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy to status indicator "J1" and to provide payment for this procedure through the Comprehensive APC payment methodology similar to the payment methodology for other surgical insertion procedures related to Brachytherapy.  CMS is proposing to assign CPT 55875 to C-APC 5375 Level 5 Urology and Related Services.  The 2017 payment for Composite APC 8001 is $3,500.25 and the proposed 2018 payment for Comprehensive APC 5375 is $3,597.65.

For 2017, CMS established several new Comprehensive APCs for Brachytherapy catheter/needle insertion codes (20555, 41019, and 55920) and other related Brachytherapy procedures such as insert tandem and/or ovoids (57155) and insert Heyman capsules (58346). Based on AAPM comments, beginning January 1, 2018 CMS is establishing a code edit that requires a Brachytherapy treatment delivery code (CPT 77750-77799) when a Brachytherapy insertion code (CPT 55875, 57155, 20555, 31643, 41018, 43241, 55920, 58346) is billed on an outpatient claim. This means that CMS will calculate the Comprehensive APC payments based on more "correctly coded" claims. Comprehensive APCs make a single payment, bundling all costs on the same claim (see table below).

Comprehensive APCs Related to Brachytherapy
C-APC CPT Codes 2017 C-APC Payment 2018 Proposed C-APC Payment Percentage Change 2017-2018
5091 Level 1 Breast/ Lymphatic Surgery 19499 Unlisted breast procedure $2,499.48 $2,628.42 5.2%
5092 Level 2 Breast Surgery 19298 Breast Brachytherapy button & tube catheter placement $4,419.46 $4,616.48 4.5%
5093 Level 3 Breast Surgery 19296 Breast Brachytherapy balloon catheter placement $6,486.35 $7,023.71 8.3%
5113 Level 3 Musculoskeletal 20555 Placement needles/catheters into muscle and/or soft tissue for subsequent interstitial radioelement application $2,438.34 $2,500.65 2.6%
5153 Level 3 Airway Endoscopy 31643 Diagnostic bronchoscope, catheter placement $1,269.79 $1,263.62 -0.5%
5165 Level 5 ENT 41019 Placement needles/catheters into head and/or neck region for radioelement application $4,130.94 $4,090.95 -1.0%
5302 Level 2 Upper GI 43241 Upper GI endoscopy, catheter placement $1,334.83 $1,375.03 3.0%
5341 Abdominal/ Peritoneal/ Biliary 55920 Placement needles/catheters into pelvic organs and/or genitalia (except prostate) for radioelement application $2,862.74 $2,788.26 -2.6%
5375 Level 5 Urology and Related Services 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy $2,542.56 $3,597.65 41.5%
5414 Level 4 Gynecological 57155 Insertion uterine tandem and/or vaginal ovoids
58346 Insertion of Heyman capsules for clinical Brachytherapy		 $2,085.47 $2,188.97 5.0%

For stereotactic radiosurgery (SRS), CMS will continue to make separate payments for the 10 planning and preparation services adjunctive to the delivery of the SRS treatment using either the Cobalt-60-based (77371) or LINAC-based (77372) technology assigned to Comprehensive APC 5627. In addition, CMS is deleting the required use of the "CP" modifier to identify services provided with 30 days of the SRS treatment but billed on a different claim.

Below is a summary of the proposed HOPPS APC payments for 2018.

Summary of 2018 Radiation Oncology HOPPS Payments
APC Description CPT Codes 2017 Payment 2018 Proposed Payment Percentage Change 2017-2018
5611 Level 1 Therapeutic Radiation Treatment Preparation 77280, 77299, 77300, 77316, 77331, 77332, 77333, 77336, 77370, 77399 $117.59 $122.37 4.1%
5612 Level 2 Therapeutic Radiation Treatment Preparation 77285, 77290, 77306, 77307, 77317, 77318, 77321, 77334, 77338 $311.57 $315.51 1.3%
5613 Level 3 Therapeutic Radiation Treatment Preparation 32553, 49411, 55876, 77295, 77301, C9728 $1,066.24 $1,158.79 8.7%
5621 Level 1 Radiation Therapy 77401, 77402, 77407, 77789, 77799 $114.35 $124.45 8.8%
5622 Level 2 Radiation Therapy 77412, 77600, 77750, 77767, 77768, 0394T $204.51 $213.83 4.6%
5623 Level 3 Radiation Therapy 77385, 77386, 77423, 77470, 77520, 77610, 77615, 77620, 77761, 77762 $494.63 $511.67 3.4%
5624 Level 4 Radiation Therapy 77605, 77763, 77770, 77771, 77772, 77778, 0395T $738.63 $694.43 -6.0%
5625 Level 5 Radiation Therapy 77522, 77523, 77525 $994.12 $941.77 -5.3%
5626 Level 6 Radiation Therapy 77373 $1,651.29 $1,635.59 -1.0%
5627* Level 7 Radiation Therapy 77371, 77372, 77424, 77425 $7,455.99 $7,335.22 -1.6%
*Comprehensive APC

A complete summary of the proposed rule and impact tables is on the AAPM website

2018 Proposed Rule Yields Positive Impact on Payments to Physicians and Freestanding Cancer Centers

The Centers for Medicare and Medicaid Services (CMS) recently released the 2018 Medicare Physician Fee Schedule (MPFS) proposed rule. The final rule will be published by November 1, with an effective date of January 1, 2018 and the AAPM will submit comments to CMS by the September 11th deadline. The MPFS specifies payment rates to physicians and other providers, including freestanding cancer centers. It does not apply to hospital-based facilities.

CMS identified the complex treatment planning code 77263 as being "potentially misvalued" under the high expenditure services review screen. The RUC recommended no change from the current work relative value units (RVUs) for the complex treatment planning code but CMS has concerns regarding the RUC-recommended work RVUs given the decrease in service times reflected in the survey data compared to the current values. The simple and intermediate treatment planning codes (77261, 77262) were also included for reviewed and are slated for work RVU reductions. CMS is seeking comment on whether their alternative valuation would be more appropriate for these codes than the RUC-recommended RVUs, which leads to lower reimbursement.

CPT Current 2017 Work RVU RUC-Recommended Work RVU CMS Alternative Valuation Work RVU
77261 1.39 1.30 1.08
77262 2.11 2.00 1.66
77263 3.14 3.14 2.60

CMS is proposing three new codes for 2018:
  • 192X1 Preparation of tumor cavity with applicator placement for intraoperative radiation therapy (IORT) concurrent with partial mastectomy
  • 55X87 Peri-prostatic implantation of biodegradable material
  • GRRR1 Superficial radiation treatment planning and management

For 2018, CMS is proposing malpractice RVUs developed using the most recent data available. For radiation oncology, malpractice premium data was only available from 23 states and does not meet the CMS 35-state threshold. CMS proposes to crosswalk the risk factor for diagnostic radiology, even though the available data suggests slightly lower premiums for radiation oncology than diagnostic radiology.

Other 2018 proposals that impact radiology and radiation oncology payment include:
  • Reduce the technical component payment by 7 percent for imaging services that are taken using computed radiography technology, defined as cassette-based imaging that utilizes an imaging plate to create the image involved. Modifier "XX" will be required on claims for the technical component of these services, including when the service is billed globally
  • The Protecting Access to Medicare Act of 2014 establishes a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging services. CMS is proposing that ordering professionals must consult specified applicable AUC through qualified clinical decision support mechanisms (CDSMs) for applicable imaging services ordered on or after January 1, 2019. The AUC program applies to advanced imaging services paid under the MPFS, hospital outpatient, and ambulatory surgical center payment systems
  • The Bipartisan Budget Act of 2015 requires that certain items and services furnished in certain off-campus provider-based departments will not be covered outpatient department services for purposes of HOPPS payment and those items and services will instead be paid under the Medicare Physician Fee Schedule beginning January 1, 2017. This law directs CMS to pay lower physician office rates to physician practices that hospitals buy and turn into outpatient departments. CMS proposes to revise the MPFS Relativity Adjuster from 50 percent of the HOPPS payment rate in 2017 to 25 percent of the HOPPS rate in 2018
As proposed, the rule would provide an overall positive one percent payment increase to radiation oncologists and freestanding cancer centers and one percent payment decrease to radiologists.

To read a complete summary of the proposed rule and to review impact tables, click here

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