CMS seeks feedback on issuing separate payment for diagnostic radiopharmaceuticals

The Centers for Medicare & Medicaid Services is seeking feedback from the field on potentially issuing separate payment for diagnostic radiopharmaceuticals—a change long sought by imaging industry advocates.

CMS issued its solicitation as part of the 2024 Hospital Outpatient Prospective Payment System proposed rule, released late Thursday. Currently, Medicare only reimburses for radiopharmaceuticals through a packaged system, regardless of product cost, but this can create a barrier for those who need expensive newer imaging agents, experts note. Professional associations have pushed to eliminate this obstacle by requiring CMS to reimburse for the contrast agent separately from the exam itself.

Bipartisan members of Congress have proposed legislation in both chambers to potentially fix this issue. And now it appears as if they have caught Medicare’s attention.

“CMS continues to believe that diagnostic radiopharmaceuticals are an integral component of many nuclear medicine and imaging procedures, and payment associated with diagnostic radiopharmaceuticals should be packaged into the payment for the imaging procedure in which they are used,” the agency said in a fact sheet issued July 13. “However, we are soliciting comment on how the OPPS packaging policy for diagnostic radiopharmaceuticals may have impacted beneficiary access, including whether there are specific patient populations, or clinical disease states, for whom this issue is especially critical.”

The American College of Radiology highlighted the solicitation in its own analysis of the OPPS rule released late Thursday. CMS is seeking comments on several potential approaches to remedy this concern “while also maintaining the principles of the outpatient prospective payment system.” They include:

  • 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.

“CMS is interested in hearing from stakeholders how the discussed policy modifications might impact their overarching goal of utilizing packaging policies to better align OPPS policies with that of a prospective payment system rather than a fee schedule,” ACR noted in its summary, adding that the college continues to review the rule and plans to issue a more detailed summary in the coming weeks. “Depending on the comments received, CMS may adopt as final one or more of the above-mentioned alternative payment mechanisms for CY2024.”

CMS is accepting feedback on the OPPS rule through Sept. 11. For further details on the proposal, you can read the agency’s fact sheet, press release, the American College of Radiology’s summary, and the American Hospital Association’s analysis.

Marty Stempniak

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. 

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