CMS Continues Comprehensive APCs in Hospital Outpatient Setting Without Addressing Data Concerns

The Centers for Medicare and Medicaid Services (CMS) recently released the 2018 Hospital Outpatient Prospective Payment System (HOPPS) final rule, which provides facility payments to hospital outpatient departments. All policies and payments are effective on January 1, 2018.

CMS finalized the proposal to eliminate the Low Dose Rate Prostate Brachytherapy Composite ambulatory payment classification (APC) for CPT 55875 + 77778 billed on the same day and instead assigned CPT 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopyto 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 assigns CPT 55875 to C-APC 5375 Level 5 Urology Services with a 2018 payment of $3,705.77.

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). AAPM conducted an economic analysis of the most recent outpatient claims data and determined that some costs of associated radiation therapy services, including brachytherapy treatment delivery, were not captured in the bundled payment. AAPM recommended that CMS discontinue the Comprehensive APC (C-APC) payment policy and proposed code edits for all brachytherapy insertion codes identified in the 2018 rule. We expressed concerns that hospital billing practices for radiation oncology services are variable and inconsistent with the C-APC policy that packages services at the claim level. AAPM noted that, in some cases, needles or catheters are surgically placed prior to the brachytherapy treatment delivery, which consists of multiple fractions over several days or weeks and may be delivered at a different site of service.

Based on AAPM's written comments, CMS did not finalize the proposal to require a code edit when a brachytherapy insertion code is billed on an outpatient claim with a brachytherapy treatment delivery code but is continuing the C-APC payment policy for these codes.

For stereotactic radiosurgery (SRS), CMS continues 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.

Based on AAPM's comments, CMS reassigned CPT 55920 Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application from Comprehensive APC 5341 Abdominal/Peritoneal/Biliary Procedures to Comprehensive APC 5415 Level 5 Gynecologic Procedures, resulting in a 43.6% payment increase.

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

Summary of 2018 Radiation Oncology HOPPS Payments
APC	Description	CPT Codes	2017 Payment	2018 Payment	Percentage Change 2017-2018
5611	Level 1 Therapeutic Radiation Treatment Preparation	77280, 77299, 77300, 77331, 77332, 77333, 77336, 77370, 77399	$117.59	$125.35	6.6%
5612	Level 2 Therapeutic Radiation Treatment Preparation	77285, 77290, 77306,77307, 77316, 77317, 77318, 77321, 77334, 77338	$311.57	$323.07	3.7%
5613	Level 3 Therapeutic Radiation Treatment Preparation	32553, 49411, 55876, 77295, 77301, C9728	$1,066.24	$1,186.60	11.3%
5621	Level 1 Radiation Therapy	77401, 77402, 77407, 77789, 77799	$114.35	$124.72	9.1%
5622	Level 2 Radiation Therapy	77412, 77600, 77750, 77767, 77768, 0394T	$204.51	$219.82	7.5%
5623	Level 3 Radiation Therapy	77385, 77386, 77423, 77470, 77520, 77610, 77615, 77620, 77761, 77762	$494.63	$522.28	5.6%
5624	Level 4 Radiation Therapy	77605, 77763, 77770, 77771, 77772, 77778, 0395T	$738.63	$714.06	-3.3%
5625	Level 5 Radiation Therapy	77522, 77523, 77525	$994.12	$1,503.44	6.0%
5626	Level 6 Radiation Therapy	77373	$1,651.29	$1,677.10	1.6%
5627*	Level 7 Radiation Therapy	77371, 77372, 77424, 77425	$7,455.99	$7,565.16	1.5%

^*Comprehensive APC

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

2018 Final 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) final rule. The MPFS specifies payment rates to physicians and other providers, as well as technical payments for freestanding cancer centers. It does not apply to hospital-based facilities. All policies and payments are effective January 1, 2018.

CMS updated the current conversion factor of $35.89 to $35.99 in 2018, which results in payment increases for the majority of radiation oncology codes.

CMS identified the complex treatment planning code 77263 as being "potentially misvalued" under the high expenditure services review screen. The simple and intermediate treatment planning codes (77261, 77262) were also included for review.

CMS finalized the RUC-recommended work relative value units (RVUs) as noted in the table below.

CPT	Current 2017 Work RVU	Final 2018 Work RVU
77261	1.39	1.30
77262	2.11	2.00
77263	3.14	3.14

CMS adds two new codes for 2018: 19294 Preparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative radiation therapy (IORT) concurrent with partial mastectomy; and 55874 Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed. CMS will notadd the proposed code (GRRR1) to describe superficial radiation treatment planning and management services.

CMS modified the proposal to revise the Physician Fee Schedule Relativity Adjuster for nonexcepted items and services furnished by nonexcepted off-campus provider-based department from 25 percent to 40 percent of the 2018 HOPPS payment rate.

In response to public comments, CMS is further delaying the effective date for the appropriate use criteria (AUC) consultation and reporting requirements for this program from January 1, 2019 as proposed to January 1, 2020.

For 2018, CMS did not finalize any of the malpractice RVUs proposals.

The 2018 final rule policies result in an overall positive one percent payment increase to radiation oncologists and freestanding cancer centers andno payment change to radiologists. To read a complete summary of the final rule and to review impact tables, click here