CMS 2021 Final Ruling Summary: Cardiac PET, MPFS, & HOPPS

  • Posted on February 09, 2021

By Kathy Francisco, Managing Partner The Pinnacle Health Group

Medicare Physician Fee Schedule FINAL Rule effective Jan 1, 2021

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On December 1, 2020, the Centers for Medicare & Medicaid Services (CMS) posted the final rule for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues for the calendar year (CY) 2021. With the budget neutrality adjustment to account for changes in relative value units (RVUs), as required by law, the final CY 2021 PFS conversion factor is $34.89, a decrease of $1.20 from the current 2020 PFS conversion factor of $36.09.

CMS also proposed changes to the direct practice expense inputs for several codes associated with Myocardial PET services. Stakeholders provided input regarding these changes that would impact CPT codes 78432, 78459, 78491, and 78492. The technical components for these CPT codes are all contractor priced so there will be no change to the national pricing of these codes for 2021. RVUs for the professional component (-26) of the myocardial imaging PET studies will remain flat with the only fluctuation in physician payment for these CPT codes corresponding to the changes associated with the conversion factor. In addition, myocardial perfusion imaging agents will continue to be contractor priced in the non-facility (office).

Code

Description

78432

Myocardial imaging, PET, combined perfusion with metabolic evaluation study (including ventricular wall
motion[s], and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability)

78459

Myocardial imaging, PET, metabolic evaluation study (including ventricular wall motion[s], and/or ejection
fraction[s], when performed), single study

78491

Myocardial imaging, PET, perfusion study (including ventricular wall motion[s], and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic)

78492

Multiple studies at rest and stress (exercise or pharmacologic)

Additionally, CMS finalized the removal of six National Coverage Determinations (NCDs) including NCD 220.2.1 Magnetic Resonance Spectroscopy and NCD 220.6.16 FDG PET for Inflammation and Infection. Local Medicare contractors will determine coverage under section 1862(a)(1) of the Act for those specific items or services previously addressed through the NCDs. These NCDs will be removed effective January 1, 2021, however, the changes in coverage require an implementation process in order to make required changes in manual guidance as well as coding/coverage/payment Medicare system edits. While it typically takes a number of months to implement a change in coverage, claims will be adjudicated appropriately, retroactive if necessary, to the effective date of the final rule, January 1, 2021.

CMS finalized the proposal to add more than 60 services to the Medicare telehealth list. These additions allow beneficiaries in rural areas who are in a medical facility (nursing home) to continue to have access to telehealth services such as certain types of emergency visits, therapy services, and critical care services. Medicare does not have the statutory authority to pay for telehealth to beneficiaries outside rural areas or allow beneficiaries to receive telehealth in their home. However, this is an Important step for Medicare beneficiaries in rural areas to have more convenient access to healthcare.


 

 PHYSICIAN OFFICE REIMBURSEMENT FINAL 2021 CHANGES

Payment rates reflect the Medicare national average payment rates ACTUAL rates for 2020 and FINAL for 2021

*MPFS rates based upon the 2021 conversion factor = $34.8931

CPT

DESCRIPTOR

Physician Global Fee

2021 FINAL*

 

78451

Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single
study, at rest or stress (exercise or pharmacologic)

 

$347.54

 

$349.28

 

78452

Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and /or stress (exercise or pharmacologic) and/or
redistribution and/or rest reinjection

 

$484.68

 

$486.41

 

78459

Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion(s) and/or ejection fraction(s), when performed, single study

Contractor Priced

Contractor Priced

 

78429

Myocardial imaging, PET, metabolic evaluation study (including ventricular wall motion(s) and/or ejection fraction(s), when performed, single study;
with concurrently acquired CT transmission

Contractor Priced

Contractor Priced

 

78491

Myocardial imaging, PET, perfusion, single study at rest or stress including ventricular wall motion(s) and/or ejection fraction(s), when performed,
single study, at rest or stress

Contractor Priced

Contractor Priced

 

78431

Myocardial imaging, PET, perfusion, single study at rest or stress Including ventricular wall motion(s) and/or ejection fraction(s), when performed, single study, at rest or stress; with concurrently acquired CT transmission

Contractor Priced

Contractor Priced

 

78492

Myocardial imaging, PET, perfusion, single study at rest or stress (including ventricular wall motion(s) and/or ejection fraction(s), when performed),
multiple studies, at rest or stress

Contractor Priced

Contractor Priced

 

78432

Myocardial imaging, PET, combined perfusion with metabolic evaluation study (including ventricular wall motion(s) and/or ejection fraction(s), when
performed), dual radiotracer (eg, myocardial viability)

Contractor Priced

Contractor Priced

 

78433

Myocardial imaging, PET, combined perfusion with metabolic evaluation study (including ventricular wall motion(s) and/or ejection fraction(s), when performed), dual radiotracer (eg, myocardial viability); with concurrently
acquired CT transmission

 

Contractor Priced

 

Contractor Priced

 

78434

Absolute quantitation of myocardial blood flow (AWMBF) PET, rest and pharmacologic stress (list separately in addition to code for primary procedure)

Contractor Priced

Contractor Priced

Contractor Priced: No formal fee schedule payment has been established; coverage and payment are subject to the Medicare Administrative Contractor review process.


PHYSICIAN OFFICE REIMBURSEMENT
FINAL 2021 CHANGES


MYOCARDIAL PERFUSION IMAGING AGENTS

CPT

DESCRIPTOR

Physician Global

2021 Physician Global FINAL*

A9500

Technetium Tc-99m sestamibi, diagnostic, per study
dose

Contractor Priced

 

 

Contractor Priced

A9502

Technetium Tc-99m tetrofosmin, diagnostic, per study
dose

A9505

Thallium Tl-201 thallous chloride, diagnostic, per millicurie

A9552

Fluorodeoxyglucose F-18 FDG, diagnostic, per study, up
to 45mci

A9555

Rubidium Rb-82, diagnostic per study dose, up to 60 millicuries

Contractor Priced: No formal fee schedule payment has been established; coverage and payment are subject to the Medicare Administrative Contractor review process.

STRESS TESTING

CPT

DESCRIPTOR

2020 Physician Global Fee

2021 Physician Global FINAL*

 

93015

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or
pharmacological stress; with supervision, interpretation and report

 

$72.18

 

$71.88

 

93016

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; supervision only, without interpretation and
report

 

$22.74

 

$21.98

 

93017

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and
report

 

$34.29

 

$35.24

 

93018

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and report only

 

$15.16

 

$14.66

 

STRESS TESTING IMAGING AGENTS

CPT

DESCRIPTOR

Physician Global

2021 Global FINAL

J0153

Injection, adenosine, 1 mg

E

$0.553

J1245

Injection, dipyridamole per 10 mg (Persantine IV)

E

$3.364

J1250

Injection, dobutamine Hydrochloride, per 250 mg

E

$7.191

J2785

Injection, regadenoson, 0.1 mg (Lexiscan)

E

$59.372

E: Excluded from Physician Fee Schedule by regulation. No RVUs are shown, and no payment may be made under the fee schedule for these codes. Payment for them, when covered, generally continues under reasonable charge procedures.  Payment is based upon Average Sales Price (ASP) fee schedule – updated quarterly by CMS

For additional details regarding CMS physician rule changes for CY2021, the 2165 page final rule may be accessed on line at https://www.cms.gov/files/document/12120-pfs-final-rule.pdf


HOSPITAL OUTPATIENT REIMBURSEMENT FINAL 2021 CHANGES

Hospital Outpatient and Ambulatory Surgery Center Final Rule

On December 2, The Centers for Medicare and Medical Services (CMS) released the final changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; New Categories for Hospital Outpatient Department Prior Authorization Process; Clinical Laboratory Fee Schedule: Laboratory Date of Service Policy; Overall Hospital Quality Star Rating Methodology; and Physician-owned Hospitals. These changes will be implemented and will impact providers effective January 1, 2021.

CMS finalized an overall increase in OPPS rates by 2.4% for 2021. For Cardiac PET procedures, there are no proposed significant changes from CY 2020 to CY 2021. Procedure reimbursement will increase slightly based upon the overall OPPS increase. Separately reimbursed procedures and packaged procedures are proposed to remain as they are currently reimbursed.
Additional changes finalized include the continuation of the current 34B drug program which allows hospitals to purchase covered outpatient drugs at discounted priced. CMS had proposed changes to the program; however, the final rule maintains the current policy of paying ASP minus 22.5% for 340B acquired drugs.

CMS also finalized the proposal to begin eliminating the Inpatient Only (IPO) list of 1,700 procedures for which Medicare will only pay when performed in the hospital inpatient. Over the next 3 years CMS will begin to eliminate IPO procedures and the list will be completely phased out by CY 2024.

 

For reimbursement support for your facility please contact your Jubilant Radiopharma Sales Representative   or email Jubilant@thepinnaclehealthgroup.com.


Payment rates reflect the Medicare national average payment rates ACTUAL rates for 2020 and FINAL for 2021

*MPFS rates based upon the 2021 conversion factor = $34.8931

Myocardial Perfusion Imaging

CPT

DESCRIPTOR

2020

2021 FINAL

2020

*2021 FINAL

OPPS

MPFS Professional

 

78451

Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress
(exercise or pharmacologic)

 

$1,272.19

 

$1,305.94

 

$68.57

 

$66.30

 

78452

Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and /or stress (exercise or pharmacologic) and/or redistribution and/or rest
reinjection

 

$1,272.19

 

$1,305.94

 

$80.84

 

$77.81

 

78459

Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion(s) and/or ejection
fraction(s), single study

 

$1,272.19

 

$1,305.94

 

$77.59

 

$74.67

 

78429

Myocardial imaging, PET, metabolic evaluation study (including ventricular wall motion(s) and/or ejection fraction(s), when
performed, single study; with concurrently acquired CT transmission

 

$1,443.16

 

$1,480.34

 

$85.53

 

$82.00

 

78491

Myocardial imaging, PET, perfusion, single study at rest or stress including ventricular wall motion(s) and/or ejection fraction(s), single
study, at rest or stress

 

$1,443.16

 

$1,480.34

 

$75.43

 

$72.23

 

78430

Myocardial imaging, PET, perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently
acquired computed tomography transmission scan

 

$1,443.16

 

$1,480.34

 

$81.20

 

$77.81

 

78431

Myocardial imaging, PET, perfusion, single study at rest or stress including ventricular wall motion(s) and/or ejection fraction(s), when performed, single study, at rest or stress; with concurrently acquired
CT transmission

 

$2,250.50

 

$2,250.50

 

$94.55

 

$90.37

 

78492

Myocardial imaging, PET, perfusion, single study at rest or stress (including ventricular wall motion(s) and/or ejection fraction(s), when
performed), multiple studies, at rest or stress

 

$1,443.16

 

$1,480.34

 

$88.78

 

$85.49

 

78432

Myocardial imaging, PET, combined perfusion with metabolic evaluation study (including ventricular wall motion(s) and/or ejection fraction(s), when performed), dual radiotracer (eg, myocardial
viability)

 

$2,750.50

 

$2,750.50

 

$100.69

 

$96.30

 

78433

Myocardial imaging, PET, combined perfusion with metabolic evaluation study (including ventricular wall motion(s) and/or ejection fraction(s), when performed), dual radiotracer (eg, myocardial
viability); with concurrently acquired CT transmission

 

$2,750.50

 

$2,750.50

 

$110.07

 

$104.68

 

78434

Absolute quantitation of myocardial blood flow (AWMBF) PET, rest and pharmacologic stress (list separately in addition to code for primary
procedure)

 

Packaged

 

Packaged

 

$31.76

 

$30.36


MYOCARDIAL PERFUSION IMAGING AGENTS

CPT

DESCRIPTOR

SI**

Payment

*2021 FINAL

A9500

Technetium Tc-99m sestamibi, diagnostic, per study dose

N

Packaged

Packaged

A9502

Technetium Tc-99m tetrofosmin, diagnostic, per study dose

N

Packaged

Packaged

A9505

Thallium Tl-201 thallous chloride, diagnostic, per mCi

N

Packaged

Packaged

A9552

Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 mCi

N

Packaged

Packaged

A9555

Rubidium Rb-82, diagnostic per study dose, up to 60 mCi

N

Packaged

Packaged

Q9969

Tc-99m from nonhighly enriched uranium source, per study dose

K

$10.00

$10.00

**Status Indicator N: Items and Services Packaged with primary procedure
**Status Indicator K: Nonpass-Through Drugs, Including Therapeutic Radiopharmaceuticals; Paid under OPPS; separate APC payment

STRESS TESTING

CPT

DESCRIPTOR

SI**

Hospital
Outpatient

2021
FINAL

Physician
Professional

*2021
FINAL

 

93015

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with supervision,
interpretation and report

 

B

 

N/A

 

N/A

 

$72.18

 

$71.88

 

93016

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring,
and/or pharmacological stress; supervision only, without interpretation and report

 

B

 

N/A

 

N/A

 

$22.74

 

$21.98

 

93017

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only,
without interpretation and report

 

Q1

 

$253.10

 

$264.45

 

$34.29

 

$35.24

 

93018

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; interpretation and
report only

 

B

 

N/A

 

N/A

 

$15.16

 

$14.66

**Status Indicator B: Not paid in this setting
**Status Indicator Q1: Payment packaged if performed with another procedure; otherwise separate payment

STRESS TESTING IMAGING AGENTS

CPT

DESCRIPTOR

SI**

2021

J0153

Injection, adenosine, 1 mg (not to be used to report any adenosine
phosphate compounds)

N

Packaged

J1245

Injection, dipyridamole per 10 mg (Persantine IV)

N

Packaged

J1250

Injection, dobutamine Hydrochloride, per 250 mg

N

Packaged

J2785

Injection, regadenoson, 0.1 mg (Lexiscan)

N

Packaged


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