A Look at the Final 2014 HOPPS Rule and What it Means for Cardiology

The Hospital Outpatient Prospective Payment System (HOPPS) rule covers payment and quality programs related to services provided in a hospital or hospital owned clinic or facility that do not involve a patient who is admitted. Many cardiology practices are paid for technical component services such as imaging under the HOPPS system because their practice is owned by a hospital system.

As part of the statutory formula that sets payments for HOPPS, the overall payment level will increase by 1.7 percent from 2013 to 2014. Because of changes in regulations and other payment inputs, payment to individual services could increase or decrease by much larger amounts between 2013 and 2014.

Payments for CT and MR

As a result of a technical change related to how charges are classified, payments for many CT and MR services will decrease between 2013 and 2014. The Centers for Medicare and Medicaid Services (CMS) originally proposed a greater reduction between 2013 and 2014 but altered their methodology slightly. For example, the national average payment for cardiac CTA will go down from $267.20 in 2013 to $222.01 in 2014, a reduction of 17 percent.

Payment for echocardiography and SPECT

Because the HOPPS system is set-up to be budget neutral, the reductions in payments for CT and MR result in increases for other services, notably echocardiography and SPECT services. For example, the payment for rest echocardiography increases from $390.49 in 2013 to $427.27 in 2014, an increase of nearly 10 percent.

Comprehensive APCs means bigger bundles of service in 2015

CMS finalized a proposal to begin paying for certain device dependent services such as ICD and PCI on a unit of payment that is more similar to the DRG system used in the inpatient hospital, but due to issues related to implementation, have delayed that implementation until 2015. In 2014, hospitals will continue to be able to submit claims for multiple services for these patients that will be paid according to their long-standing rules regarding what is packaged. However, starting in 2015, if a hospital bills for a service such as an ICD placement, all other services will be packaged. This move in 2015 will make the outpatient hospital payment system more similar to the inpatient. As CMS is still working through the implementation details, the ACC will provide more throughout 2014 looking forward to this implementation.

Payment for Outpatient Service provided in hospital-owned clinics

In 2014, CMS will pay the same rate to hospital-owned clinics for office visits, regardless of whether the patient is new or established, and will not recognize the five levels of service within the CPT guidelines. This only applies to the hospital portion of the service. Services in physician-owned offices will not be affected. In addition, there will still be differentiation for the professional portion of the service, although those codes are not listed with a split of technical and professional component. CMS has done this because hospitals are not subject to consistent regulation about establishing levels of visits, but merely had to establish their own standards. CMS will no longer pay hospitals that submit bills for CPT codes 99201-99205 and 99211-99215 but instead has instructed hospitals to report code G0463. CMS had proposed to similarly pay the same for all levels of emergency room care but did not finalize that proposal.

Packaging of Services

CMS has decided to package a number of services starting in 2014 so that they are no longer separately paid when provided with another service. In some cases, this is dependent upon the primary service being provided but in some cases it is unconditional. While many of these services are packaged, hospitals must still report the associated CPT codes.

  • Clinical Labs: Medicare will no longer pay for clinical laboratory services that are an integral or supportive part of a primary service. They indicate that these tests will be considered to be packaged if they are ordered by the provider of the primary service and if they are provided on the same date.
  • Stress Agents: Medicare will no longer separately pay for stress agents provided for tests such as myocardial perfusion imaging when patients are unable to exercise. The radiopharmaceutical used for diagnosis in this procedure has been packaged for a number of years.
  • Stress Tests for MPI:CMS will no longer separately pay for the stress tests associated with myocardial perfusion imaging. Instead, that payment will be reflected in the overall payment for the stress MPI test. Since this is almost always provided, it should have relatively little effect on the payment.
  • Device Removal: CMS will no longer separately pay for device removal when performed on the same day as a device revision in which the removal is an integral part of the service.

Services not packaged as proposed

CMS had proposed to package a number of diagnostic services in a similar manner as the items described above but did not finalize this proposal. This means that services such as echocardiography will continue to be separately paid when provided on the same day as another hospital service.

Payment for subcutaneous ICD

CMS will pay for subcutaneous implantable cardioverter defibrillators under the same payment rate used for ICDs with trans-venous leads, at approximately $25,000 based on national payment rates. Hospitals should report CPT code 0319T.

Payment for sympathetic innervation imaging

CMS will pay for sympathetic innervation imaging at a rate that is most similar to a SPECT myocardial perfusion test at a rate of approximately $1158. Hospitals should report CPT codes 0331T and 0332T.

Cardiac rehabilitation performance measure removed

CMS removed a cardiac rehabilitation performance measure that had been added last year but for which data had never been collected. CMS indicated that it had been difficult for hospitals to identify the correct visit which a patient should be prescribed cardiac rehab services. The measure remains available as part of the physician quality reporting system.

Keywords: Myocardial Perfusion Imaging, Emergency Medical Services, Tomography, Emission-Computed, Single-Photon, Diagnosis-Related Groups, Centers for Medicare and Medicaid Services, U.S., Inpatients, Clinical Laboratory Services, Outpatients, Device Removal, Office Visits, Defibrillators, Implantable, Echocardiography, Prospective Payment System, Exercise Test

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