Imaging advocates express frustration with final hospital outpatient payment rule
Imaging advocates are expressing disappointment following the recent release of the 2026 Hospital Outpatient Prospective Payment System (HOPPS) final rule.
The Centers for Medicare & Medicaid Services issued the key update on Nov. 21, incorporating a 2.6% increase to the conversion factor, up to $91.415. In its analysis of the rule, the American College of Radiology highlighted higher-than-expected payment classifications for both 3D printing (at $381.24) and noncardiac, contrast-enhanced ultrasound ($243.77).
Meanwhile, two nuclear medicine-focused societies are voicing frustration following Medicare’s announcement last month. In particular, the American Society of Nuclear Cardiology (ASNC) highlighted the reassignment of CPT code 78803 (for a single SPECT scan to localize tumors, inflammation or the distribution of a radioactive agent). Now classified as a level 2 service (APC 5592), this will result in a 57% reduction in reimbursement for certain scans.
“Despite ASNC’s strong advocacy, directly with CMS, and YOUR grassroots efforts, the agency finalized proposals unfavorable to nuclear cardiology,” the society said in a recent news update.
ASNC had argued that Medicare’s new policy of paying separately for radiopharmaceuticals over a certain threshold could be impacting the geometric mean for CPT 78803. It believed the agency should delay reassigning the code to allow time for hospitals to adjust, and for additional data to accumulate. However, CMS opted not to accept this feedback, only promising it would examine the code’s reassignment in the next rulemaking cycle.
“In the meantime, ASNC will redouble efforts to educate members about hospital cost reporting and how it can impact reimbursement,” the society said.
CMS also finalized a new add-on payment of $10 per dose for Tc-99m, a radioactive isotope used in nuclear medicine. To qualify for reimbursement, at least 50% of the Mo-99 used in the Tc-99m generator must be domestically produced. This comes as the U.S. remains heavily dependent on foreign isotope production, with reported progress in the establishment of a domestic supply.
“ASNC is encouraged that CMS is cognizant of additional costs associated with U.S. production and supportive of additional reimbursement when domestically sourced Mo-99 becomes available,” the group wrote.
The Society of Nuclear Medicine and Molecular Imaging (SNMMI) also highlighted the new add-on payment in its own analysis. It encouraged CMS to provide clear guidance on the documentation hospitals must maintain to verify eligibility for the payment. SNMMI also wants the agency to implement periodic reviews of the dollar amount to ensure payment “remains adequate as domestic production capacity grows and costs evolve.” The society is urging CMS to expand the add-on payment to include other radiopharmaceuticals used in lung, brain and thyroid imaging.
Meanwhile, SNMMI criticized the agency’s refusal to adopt an average-sale-price-based payment for diagnostic radiopharmaceuticals. Instead, CMS is utilizing average unit cost, which the agency believes is a more accurate way of calculating reimbursement.
“SNMMI is disappointed by this decision,” the society said. “We believe that paying for non-pass-through diagnostic radiopharmaceuticals using the arithmetic mean unit cost is inappropriate, as it does not reliably reflect the average price of a non-pass-through separately payable diagnostic radiopharmaceutical. While [mean unit cost] reflects hospital-reported claims data, it often fails to capture actual acquisition costs due to variability in hospital reporting practices and the lag when costs are incurred and their appearance in cost reports.”
For much more on the final HOPPS final rule, you can read the CMS press release and fact sheet, along with analyses from the American College of Radiology, Society of Interventional Radiology, and the American Society for Radiation Oncology.
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.