CMS declines to issue imaging agent reimbursement fix in final hospital outpatient payment rule
The Centers for Medicare & Medicaid Services recently released its final Hospital Outpatient Prospective Payment System rule, which does not include changes to reimbursement bundling for diagnostic radiopharmaceuticals.
CMS previously issued the initial proposed rule in July, soliciting feedback from the field on potentially granting a separate payment for such contrast agents, rather than lumping them together with the exam. Industry advocates have long fought for this change, noting that the current bundling system creates a barrier for those who need expensive newer contrast agents.
The agency said Nov. 2 that it received “considerable interest” in the comment solicitation, with respondents providing “various insights and potential policy changes.” CMS emphasized it still thinks that diagnostic radiopharmaceuticals should be packaged into the payment for the imaging procedure in which they are used.
“We believe this is a complex and vital issue, and given the vast array of information presented through the public comment process, we intend to further consider these points for future notice and comment rule-making,” the agency said in a fact sheet published alongside the final HOPPS rule. “We welcome ongoing dialogue and engagement from stakeholders regarding suggestions for potential future payment changes, including on any of the five potential solutions included in the original comment solicitation, as well as any other potential solutions.”
CMS suggested potential policy changes in the original proposed rule, including:
- Paying separately for diagnostic radiopharmaceuticals with per-day costs above the OPPS drug packaging threshold of $140.
- Establishing a specific per-day cost threshold that may be greater or less than the OPPS drug packaging threshold.
- Restructuring [Ambulatory Payment Classification], including by adding nuclear medicine APCs for services that utilize high-cost diagnostic radiopharmaceuticals.
- Creating specific payment policies for diagnostic radiopharmaceuticals used in clinical trials.
- Adopting codes that incorporate the disease state being diagnosed or a diagnostic indication of a particular class of diagnostic radiopharmaceuticals.
Overall, the Hospital Outpatient Prospective Payment System final rule will increase the conversion factor by 3.1% in 2024, up to $87.382.
The American College of Radiology recently issued a preliminary summary of the policy, while the American Society of Nuclear Cardiology also commented.
Bipartisan members of Congress proposed legislation in both chambers earlier this year to potentially fix the radiopharmaceutical bundling issue, but the bills have yet to find passage.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.