Reimbursement Update

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The downs are outdoing the ups in radiology and radiation oncology reimbursement these days, but smart administrators can often find ways around falling numbers. Keep your ear to the ground and support professional organizations that can make a difference.

The Centers for Medicare and Medicaid Services (CMS) published preliminary rules for 2005 reimbursement this summer. While the Feds haven't dotted their i's and crossed their t's, it is time to prep for the upcoming changes. Some proposed rules could dramatically impact payment for and utilization of imaging technologies. PET, for example, has been losing ground in recent years and is threatened by a decrease of nearly 40 percent in the upcoming year if a preliminary option is implemented.

Other technologies, including CT angiography, intensity modulated radiation therapy (IMRT) and proton beam therapy, stand to lose ground as well. CMS plans to move these procedures to different clinical APCs (ambulatory patient categories). Many of the changes are based on flawed early data from hospitals, says Diane Wurzberger, director of health policy and reimbursement for Siemens Medical Solutions, (Malvern, Pa.) and will result in a significant decrease in reimbursement rates if implemented.

And let's not forget private payors. Many are proposing and making changes that could affect providers across the enterprise. Increased private reimbursement for digital mammography and separate payments for CAD could become ancient history over the next few years. Private payors also are scrutinizing contiguous CT scans, 3D reconstructions, 0.3 T MRI scans and teleradiology payments.

THE UPS AND DOWNS OF PET REIMBURSEMENT

This summer CMS put PET reimbursement for Alzheimer's on the books. Michael Weiner, M.D., director of the Center for Imaging of Neurodegenerative Disease at the VA Medical Center (San Francisco) and chair of the Alzheimer's Association Neuroimaging Work Group, says, "This is great news for Alzheimer's patients." Although the radiology community has been waiting for PET reimbursement for Alzheimer's for a few years, this initial coverage represents a mere toe in the door. Weiner explains, "A very limited subset of patients will be eligible for PET scans under this ruling." That is, patients must have had a complete clinical workup and meet the diagnostic criteria for both Alzheimer's and frontotemporal dementia with an uncertain evaluation for the clinical cause. And the PET scan should be helpful in changing the patient's treatment or management.

Weiner says The Alzheimer's Association (Chicago) does not believe broad reimbursement for Alzheimer's is appropriate at this time; if there was broad reimbursement, PET scanning could be overused as a first line diagnostic tool. A single imaging exam cannot be used for a diagnosis of Alzheimer's, asserts Weiner.

There could be more positive news about the PET-Alzheimer's connection in the future. The Alzheimer's Disease Neuroimaging Initiative, a $60 million endeavor to research MRI, PET and biomarkers to help develop better clinical trials, will yield tremendous information about the role of PET in Alzheimer's, says Reiner.

But the positive PET news ends with the Alzheimer's addition. PET has seen reimbursement drop from approximately $2,100 when it was first approved to about $1,450 for a scan and $324 for FDG in 2004. CMS is considering another round of hefty cuts and has put three options on the table for PET reimbursement in 2005. These are:

  • Option one - leave payments at $1,450 and reduce FDG reimbursement to $220. This option retains the current APC and would allow CMS to continue to collect additional claims data.
  • Option two - reclassify the APC and slash PET reimbursement to $898 and FDG reimbursement to $220.
  • Option three - reclassify the APC and drop PET reimbursement to $1,150 and

FDG reimbursement to $220. This is likely a transitional option and could lead to another drop in 2006.

Wurzberger says industry is supporting option one as the alternates seem to be based on inaccurate claims data. One more year of data gathering could help CMS develop a more accurate payment. Indeed, hospital, physicians, vendors and professional organizations agree that further cuts in reimbursement could limit access to the technology and threaten the viability of newer PET providers.

Thomas Dehn, MD, chief medical officer for National Imaging Associates, a radiology benefits management company in Hackensack, N.J., adds to the list