CMS cuts reimbursement for cardiac PET by 23% in 2011

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Coronary CTA with PET fusion. Source: Siemens Healthcare

The Centers for Medicare & Medicaid Services (CMS) will reduce cardiac PET reimbursement by 23 percent, effective Jan. 1, 2011, as part of its final rule for the Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Center (ASC) services.

The proposed final rule includes a minor reduction in reimbursement for nuclear cardiology services and more significant cuts for cardiac PET. The final rule includes the -0.25 percent reduction as required by law under the Patient Protection & Affordable Care Act. In addition, certain hospitals that did not meet the quality reporting requirements will face a 2 percent reduction.

The American Society of Nuclear Cardiology said in a statement that it will submit comments to CMS on the final rule, which was published in the Federal Register on Nov. 24. Comments are due to CMS by Jan. 3, 2011. CMS will respond to comments in the CY 2012 HOPPS/ASC final rule.

The proposed 2011 HOPPS rates with the final 2010 HOPPS rates for codes relevant to nuclear cardiology are:

  • 78451-2 -- MPI, SPECT, single or multiple studies, a decrease from $773.20 to $768.38, -1 percent change.
  • 78453-4 -- Heart muscle image, planar, single and multiple, a decrease from $773.20 to $768.38, -1 percent change.
  • 78459 -- Heart muscle imaging (PET), a decrease from $1,429.36 to $1,099.16, -23 percent change.
  • 78491-2 -- Heart image PET, single and multiple, a decrease from $1,429.36 to $1,099.16, -23 percent change.
  • 75571 -- CT heart w/o dye w/ calcium test, an increase from $45.00 to $47.10, +5 percent change.
  • 75572 -- CT heart w/ 3D image, an increase from $224.19 to $258.02, +15 percent change.
  • 75573 -- CT heart w/ 3D image, congenital, a decrease from $325.22 to $258.02, -21 percent change.
  • 75574 -- CT angio heart w/ 3D image, a decrease from $268.49 to $258.02, -4 percent change.
  • 93017 -- Cardiovascular stress test, an increase from $175.74  to $179.55, +2 percent change.

Stakeholders have objected to the proposed decrease in the payment rate for myocardial PET imaging. Several alternate suggestions for limiting major fluctuations were offered to CMS. CMS said it examined the data for myocardial PET under Ambulatory Payment Classification (APC) 0307 and found that the charges were stable, that the cost-to-charge ratios (CCRs) used to estimate cost from charges for these codes declined, and that the cost of HCPCS code A9555 (rubidium-82), the radiopharmaceutical that is used in a myocardial PET scan, also declined.

Specifically, the median CCR for 78492 declined from 0.2342 in 2010 HCRIS data to 0.1708 in 2011 final rule claims data. Moreover, the estimated per-day cost of rubidium declined from $418.05 per day in 2010 to $330.06 in 2011 final rule claims data.

CMS agreed that the modest number of hospitals that furnish the service (50 in 2010 final rule claims data and 61 in 2011 final rule claims data), and the addition of claims from 11 hospitals that reported the service for the first time in 2009, may have some bearing on the volatility in the median costs. CMS will continue to monitor these data in the future.

CMS continues packaging for multiple imaging services, without modification, in 2011. Modalities affected are CT and cardiac CTA, MRI, MRA and ultrasound services. Nuclear cardiology is again currently NOT one of the modalities selected in this policy. Under the policy, CMS would make a single payment for multiple services provided on the same date of service, of the identified modalities, through five imaging composite APC groups.