Medicare to boost payment for certain diagnostic imaging agents
The Medicare program on Friday finalized plans to boost payment for certain diagnostic imaging agents delivered in the hospital outpatient setting.
First outlined in July, CMS is now moving forward with a proposal to issue separate payment for radiopharmaceuticals—a change long lobbied for by the imaging industry. For years, the agency has packaged payment for nuclear imaging agents with the procedure. However, this can create a barrier for those who require newer radiopharmaceuticals, advocates note.
Beginning Jan. 1, CMS will pay separately for diagnostic imaging agents with per-day costs above a threshold of $630. The Society of Nuclear Medicine & Molecular Imaging applauded the announcement Friday.
“This decision is a critical victory for patients who need advanced diagnostic care,” SNMMI President Cathy Sue Cutler, PhD, said in a statement. “We commend CMS for this significant move to improve access to life-saving nuclear medicine scans, ensuring that patients across the country can receive the best possible care.”
The policy was finalized as part of the 2025 Hospital Outpatient Prospective Payment System final rule shared Nov. 1. Unbundling will impact 26 different radiopharmaceuticals, the American Society of Nuclear Cardiology noted in a separate announcement. This means payment for Rb-82, N-13, and many other cardiac agents will remain bundled into procedure reimbursement.
SNMMI said it has advocated for this change for the past 16 years, submitting numerous letters to CMS and coordinating meetings with congressional reps. The final policy decision also will eliminate the need for the FIND (Facilitating Access to Innovative Diagnostics) Act, which hundreds of organizations pushed for in recent months.
“This win is truly a community achievement,” Cutler added. “We are deeply grateful to SNMMI members, patients, healthcare providers and community advocates who joined us in supporting this important cause."
All qualifying radiopharmaceutical products will be paid separately at the average unit cost, which is a payment rate derived from hospital claims data. Any imaging agents with a per-day cost at or below $630 will continue to be policy-packaged with procedures.
“This update should address challenges for patients in accessing these prescribed nuclear medicine tests with higher-cost radiopharmaceuticals,” CMS said in a fact sheet issued Nov. 1.
Radiopharmaceutical manufacturers Blue Earth Diagnostics and Lantheus also applauded the decision on Monday.
For more on the OPPS final rule, you can read this CMS news announcement, and preliminary summaries from the American College of Radiology and American Hospital Association. SNMMI also said it plans to hold a webinar about the decision’s impact on coding and reimbursement.
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.