CMS Updates Radiation Oncology Supply and Equipment Pricing

The Centers for Medicare and Medicaid Services (CMS) recently released the 2019 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, 2019.

CMS updated the current conversion factor of $35.99 to $36.04 in 2019, which results in a small payment increase for many radiation oncology codes.

CMS initiated a contract with StrategyGen to conduct an in-depth and robust market research study to update the direct practice expense (PE) inputs for medical supply and equipment pricing beginning in 2019. These supply and equipment prices were last systematically developed in 2004–2005. After consideration of public comments, CMS finalized the policy to update the StrategyGen pricing recommendations for approximately 1,300 supplies and 750 equipment items. Given the potentially significant changes in payment that may occur, CMS will phase-in the use of the new direct practice expense input pricing over a 4-year period from 2019 through 2022.

Based on public comment, CMS did revise the pricing for approximately 60 supply and equipment codes, including six equipment items used in radiation oncology (see table below). This policy significantly decreases future reimbursement for stereotactic body radiation treatment (SBRT) delivery.

The 2019 final rule policies result in an overall one percent payment decrease to radiation oncologists and freestanding cancer centers and no payment change to radiologists.

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

CMS Finalizes Medicare Hospital Outpatient Prospective Payment System Changes for 2019

The Centers for Medicare and Medicaid Services (CMS) recently released the 2019 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, 2019. This rule does not impact payments to physicians or freestanding cancer centers.

CMS estimates an overall 1.35 percent increase in hospital outpatient facility payments in 2019. Final 2019 payment changes for radiation oncology related Ambulatory Payment Classifications (APCs) range from negative 6.2 percent to a 2.4 percent increase in payment. Payment for medical physics consultation codes 77336 and 77370 have a nominal 1.3 percent payment decrease in 2019.

CMS did not implement AAPM's request to discontinue the Comprehensive APC (C-APC) payment policy for several brachytherapy device insertion procedures and single session stereotactic radiosurgery (SRS) procedures. CMS stated that they continue to believe that the C-APC policy is appropriately applied to these surgical procedures for the reasons cited when the policy was first adopted and note that the commenters did not provide any empirical evidence to support their claims that the existing C-APC policy does not adequately pay for these procedures.

CMS will continue in 2019 to pay separately for the 10 planning and preparation services (CPT codes 70551, 70552, 70553, 77011, 77014, 77280, 77285, 77290, 77295, and 77336) adjunctive to the delivery of the stereotactic radiosurgery treatment using either the Cobalt-60-based or LINAC based technology when furnished to a beneficiary within one month of the SRS treatment.

CMS is exercising its authority under the law to utilize a method to control unnecessary increases in the volume of covered hospital outpatient department services by applying a Medicare Physician Fee Schedule (MPFS)-equivalent payment rate for the clinic visit (G0463) service when provided at all off-campus provider-based departments (PBDs) that are paid under the HOPPS. The clinic visit is the most common service billed under the HOPPS and is often furnished in the physician office setting. CMS is implementing this policy in a non-budget neutral manner. CMS will phase-in the application of the reduction in payment for HCPCS code G0463 in this setting over two years. This policy will result in lower copayments for beneficiaries and savings for the Medicare program in an estimated amount of $380 million for 2019.

Below is a summary of the final HOPPS APC payments for 2019.

Summary of 2019 Radiation Oncology HOPPS Payments

APC	Description	CPT Codes	2018 Payment	2019 Payment	Payment Change 2018-2019	Percentage Change 2018-2019
5611	Level 1 Therapeutic Radiation Treatment Preparation	77280, 77299, 77300, 77331, 77332, 77333, 77336, 77370, 77399	$125.35	$123.77	($1.58)	-1.3%
5612	Level 2 Therapeutic Radiation Treatment Preparation	77285, 77290, 77306, 77307, 77316, 77317, 77318, 77321, 77334, 77338	$323.09	$321.82	($1.27)	-0.4%
5613	Level 3 Therapeutic Radiation Treatment Preparation	32553, 49411, 55876, 77295, 77301, C9728	$1,186.68	$1,191.92	$5.24	0.4%
5621	Level 1 Radiation Therapy	77401, 77402, 77789, 77799	$124.73	$116.99	($7.74)	-6.2%
5622	Level 2 Radiation Therapy	77407, 77412, 77600, 77750, 77767, 77768, 0394T	$219.83	$224.46	$4.63	2.1%
5623	Level 3 Radiation Therapy	77385, 77386, 77423, 77470, 77520, 77610, 77615, 77620, 77761, 77762	$522.31	$519.85	($2.46)	-0.5%
5624	Level 4 Radiation Therapy	77605, 77763, 77770, 77771, 77772, 77778, 0395T	$714.11	$704.72	($9.39)	-1.3%
5625	Level 5 Radiation Therapy	77522, 77523, 77525	$1,053.52	$1,078.97	$25.45	2.4%
5626	Level 6 Radiation Therapy	77373	$1,677.22	$1,690.57	$13.35	0.8%
5627*	Level 7 Radiation Therapy	77371, 77372, 77424, 77425	$7,565.69	$7,644.24	$78.55	1.0%

^*Comprehensive APC
BOLD = APC Reassignment for 2019

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