On July 8, 2013, the Centers for Medicare and Medicaid Services (CMS) released the 2014 Hospital Outpatient Prospective Payment System (HOPPS) proposed rule, covering payments and related policies for services provided in the hospital outpatient setting. The ACC is currently reviewing the rule in preparation to submit comments at the end of the summer. Some of the key provisions include:

Payment changes for imaging services
CMS proposes to use new cost centers for CT, MR and cardiac catheterization. This technical change alters the calculations for payments for many commonly provided services. The use of these new cost centers would result in decreases in payment for CT and MR services but increases in payment for services such as echocardiography and nuclear stress tests. For example, coronary CTA would be cut by approximately 14 percent and nuclear stress imaging would increase in payment by a similar amount. 

Stress myocardial perfusion imaging packaged payment
CMS proposes to package together services that are commonly performed together and pay for them as a single package. The most notable example of this packaging proposal is for stress myocardial perfusion imaging, which can include as many as four distinct services related to the imaging and the stress test.  CMS proposes a new payment method that accommodates all of this in a single package. 

Establishment of comprehensive APCs for EP services
A number of common electrophysiology services will be paid under what CMS has termed “comprehensive” APCs. This means that a single payment will be made for the entire service rather than each component being paid. In some cases, some of these services were paid under a “composite” APC that required different coding.

PCI add-on payments
In a similar attempt to bundle together services, CMS has proposed to stop making separate payment for add-on services, such as the payments made for additional vessels in PCI services. These PCI add-on codes were bundled into the base codes as part of the physician fee schedule in 2013 but are currently being paid in the hospital outpatient setting.

Elimination of multiple levels of E/M visit
CMS has proposed to establishment a single payment level for outpatient observation and ER visits, instead of the multiple levels of visits that are currently paid at different rates. CMS has experienced issue with proper coding of these services. 

Consideration of hospital-owned clinics
CMS notes the increasing number of hospital-owned clinics, which are very common in cardiology.  While they do not propose any changes, they indicate that they are considering methods to gather information about the costs for these practices. 

Removal of cardiac rehab measure
CMS proposes to remove a performance measure covering the use of cardiac rehab on patients in the outpatient setting. CMS proposes to do this due to issues identifying what is meant by the “outpatient setting” and concern that services performed in a hospital outpatient setting may not apply to the measure. 
Because of the many systemic changes being proposed in this rule, it can be difficult to identify payment differences from one year to the next. This is particularly true for services that were commonly paid under multiple Ambulatory Payment Classifications (APCs) in previous years. 

Keywords: Myocardial Perfusion Imaging, Electrophysiology, Outpatients, Cardiac Catheterization, Centers for Medicare and Medicaid Services, U.S., United States, Prospective Payment System, Echocardiography, Exercise Test

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