Medicare announces final changes to the Hospital Outpatient Prospective Payment System (HOPPS) and 2009 Payment Rates [Cardinal Health PET Perspectives eNews]

Medicare announces final changes to the Hospital Outpatient Prospective Payment System (HOPPS) and 2009 Payment Rates

November 3, 2008

The Centers for Medicare and Medicaid Services (CMS) has released an advance copy of the Final Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2009 Payment Rates (CMS-1404-FC). The final rule is expected to be published in the Federal Register on November 18, 2008.

The changes will be effective for services performed on or after January 1, 2009.

Effect on PET and PET/CT Reimbursement:

CMS will to continue to package the payment for ALL diagnostic radiopharmaceuticals into the payment for the scan (i.e. the nuclear medicine procedure APC payment rate).
The final rule maintains the assignment of all cardiac PET CPT codes to APC 0307 – Myocardial Positron Emission Tomography (PET) imaging, with a decrease in the payment for APC 0307 from $1,400.98 in 2008 to $1,156.87 in 2009.
The final rule maintains the assignment of all non-cardiac PET and PET/CT CPT codes to APC 0308 – Non-Myocardial Positron Emission Tomography (PET) imaging, with a decrease in the payment for APC 0308 from $1,057.33 in 2008 to $1,036.92 in 2009.

The following table summarizes the final changes by CMS for payments for PET scans for 2009 under HOPPS:

CPT Code	Description	APC 2008	Payment 2008	APC 2009	Payment 2009
78459	PET, Myocardial, metabolic evaluation	0307	$1,400.98*	0307	$1,156.87*
78491	PET, Myocardial perfusion single study	0307	$1,400.98*	0307	$1,156.87*
78492	PET, Myocardial perfusion multiple studies	0307	$1,400.98*	0307	$1,156.87*
78608	PET, Brain, metabolic evaluation	0308	$1,057.33*	0308	$1,036.92*
78811	PET imaging, limited	0308	$1,057.33*	0308	$1,036.92*
78812	PET imaging, skull base to mid-thigh	0308	$1,057.33*	0308	$1,036.92*
78813	PET imaging, whole body	0308	$1,057.33*	0308	$1,036.92*
78814	PET/CT imaging, limited	0308	$1,057.33*	0308	$1,036.92*
78815	PET/CT imaging, skull base to mid-thigh	0308	$1,057.33*	0308	$1,036.92*
78816	PET/CT imaging, whole body	0308	$1,057.33*	0308	$1,036.92*

*Includes payment for PET radiopharmaceuticals

Although the payment for diagnostic radiopharmaceuticals is packaged into the payment for the scan, CMS requires 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. This policy was implemented by CMS January 1, 2008, and CMS will continue the policy for 2009 under HOPPS.

The following table lists the PET radiopharmaceutical HCPCS codes and payment methodology under HOPPS:

HCPCS Code	Description	Payment 2008	Payment 2009
A9552	FDG, per dose	Packaged into scan payment APC	Packaged into scan payment APC
A9555	Rubidium-Rb-82, per dose	Packaged into scan payment APC	Packaged into scan payment APC
A9526	Ammonia N-13, per dose	Packaged into scan payment APC	Packaged into scan payment APC

CMS-1404-FC, Final Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2009 Payment Rates can be found at: www.cms.hhs.gov/hospitaloutpatientpps/
CMS has posted a related press release 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.