PET Perspectives | Cardinal Health

November 8, 2007

Medicare Announces Final Changes to the Hospital Outpatient Prospective Payment System (HOPPS) and 2008 Payment Rates

The Centers for Medicare and Medicaid Services (CMS) has posted on its website an advanced copy of the final Changes to the Medicare Hospital Outpatient Prospective Payment System (HOPPS) and Calendar Year 2008 Payment Rates (CMS-1392-FC). The final rule will be published in the Federal Register on November 27, 2007.

The changes will be effective for services performed on or after January 1, 2008.

Effect on PET and PET/CT Scan Reimbursement:

CMS will package the payment for ALL diagnostic radiopharmaceuticals into the payment for the scan.

Note: Currently the CMS payment policy is to package some radiopharmaceuticals and to pay separately for radiopharmaceuticals that CMS has determined to have an average cost threshold of over $55, and payment is based on the hospital’s charge for each radiopharmaceutical adjusted to cost using hospital specific overall cost-to-charge ratios (CCRs).
Although payment for diagnostic radiopharmaceuticals will be packaged into the payment for the scan, CMS will require providers to bill for the diagnostic radiopharmaceutical used in conjunction with the nuclear medicine procedure performed. Moreover, CMS will return to providers any claim for a nuclear medicine study that does not also contain a HCPCS code and charge for a diagnostic radiopharmaceutical.
CMS has reassigned the PET/CT codes from APC 1511 – New Technology-Level XI to APC 0308 – Non-Myocardial Positron Emission Tomography (PET) imaging. Therefore all the non-cardiac PET CPT codes will be assigned to a single APC 0308, with a new payment rate of $1,057.33.
The final rule maintains the assignment of all cardiac PET CPT codes to APC 0307 – Myocardial Positron Emission Tomography (PET) imaging, with a new payment rate of $1,400.98

PET scan payment changes under 2008 HOPPS:

CPT CODE	DESCRIPTION	APC 2007	PAYMENT 2007	APC 2008	PAYMENT 2008
78459	Myocardial imaging, PET, metabolic evaluation	0307	$731.24	0307	$1,400.98*
78491	Myocardial imaging, PET, perfusion, single study	0307	$731.24	0307	$1,400.98*
78492	Myocardial imaging, PET, perfusion multiple studies	0307	$731.24	0307	$1,400.98*
78608	Brain imaging, PET, metabolic evaluation	0308	$855.43	0308	$1,057.33*
78811	PET imaging, limited	0308	$855.43	0308	$1,057.33*
78812	PET imaging, skull base to mid-thigh	0308	$855.43	0308	$1,057.33*
78813	PET, imaging, whole body	0308	$855.43	0308	$1,057.33*
78814	PET/CT imaging, limited	1511	$950.00	0308	$1,057.33*
78815	PET/CT imaging, skull base to mid-thigh	1511	$950.00	0308	$1,057.33*
78816	PET/CT imaging, whole body	1511	$950.00	0308	$1,057.33*

*Includes payment for PET radiopharmaceuticals

Note: The CPT code descriptions for the PET and PET/CT CPT codes (78811-78816) have been revised to remove the term “tumor” from the descriptions effective January 1, 2008. These are code description changes only, not PET coverage changes, and current Medicare PET coverage policies still apply.

PET radiopharmaceutical payment changes under 2008 HOPPS:

HCPCS CODE	DESCRIPTION	APC 2007	PAYMENT 2007	APC 2008	PAYMENT 2008
A9552	FDG, per dose	1651	Hospital specific overall CCR	n/a	Packaged into scan payment APC
A9555	Rubidium-Rb-82, per dose	1654	Hospital specific overall CCR	n/a	Packaged into scan payment APC
A9526	Ammonia N-13, per dose	0737	Hospital specific overall CCR	n/a	Packaged into scan payment APC

The final rule; Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2008 Payment Rates (CMS-1392-FC) can be found at:
www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp

CMS has posted a related press release on the proposed rule that can be found at:
www.cms.hhs.gov/apps/media/press/release.asp

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Reimbursement information is provided by Cardinal Health as general coding and payment information. This information is not intended to replace or serve as substitute for your duty to verify that such information is proper for your particular circumstances. Any codes reported should accurately reflect the procedures performed and the patient's conditions. You may want to consult with local payers to confirm compliance with local policies, or otherwise review and confirm reimbursement policies with your own legal or other professional advisors.