2012 Nuclear Medicine Update Presented by Barbara Ossias

2012 Nuclear Medicine Update Presented by Barbara Ossias Sponsored by UPPI

Agenda Overview of the 2012 Changes with Medicare • HOPPS • MPFS including SGR Update Coding Changes Healthcare Reform in 2012 Q & A

2012 Changes HOPPS The HOPPS payment rates increased by 1. 9% on January 1 st CMS estimates that payments will total $41. 1 billion for 4, 000 hospitals, including general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children's hospitals, and cancer hospitals • Cancer hospitals specifically will see increased payments of 11. 3% (approximately $71 million)

2012 Changes HOPPS - Packaging 2012 will see continued packaging of payment for services and agents in seven categories into the reimbursement for the primary diagnostic or therapeutic procedure; these are services and agents that CMS has deemed ancillary to the primary procedure The seven categories are: • Guidance services • Image processing services • Intraoperative services • Imaging supervision and interpretation services • Diagnostic radiopharmaceuticals • Contrast media • Observation services

2012 Changes HOPPS - Packaging Despite comments on the unique nature of radiopharmaceuticals and issues like special handling and disposal requesting acquisition and pharmacy overhead costs, including compounding costs CMS held firm in not making separate reimbursement for these agents

2012 Changes HOPPS – Pass-thru The HOPPS Final Rule established that CMS will continue to update payment rates on products having been granted pass-through status on a quarterly basis on the CMS Web site during CY 2012 and reiterated that CMS considers radiopharmaceuticals to be drugs under HOPPS Per the Final Rule, any diagnostic or therapeutic radiopharmaceutical that receives pass-through status during CY 2012 will be reimbursed at the standard ASP methodology as basis of pass-through payment rate

2012 Changes HOPPS - PET In 2012 CMS continued the assignment of PET myocardial procedures to APC 0307 (Myocardial Position Emission Tomography (PET) Imaging) with a national unadjusted rate of $921 in the Final Rule This is a significant decrease from the 2011 national unadjusted rate of $1, 107 Given that all diagnostic radiopharmaceuticals are packaged into the APC for the related procedure, this decrease might have a negative impact on the facilities offering these procedures

2012 Changes HOPPS - PET After reviewing additional comments that came in on the Final Rule CMS changed the APC assignment for cardiac PET to APC 308 In adding cardiac PET into APC 0308 CMS revised the national unadjusted rate to be $1, 036. 95

2012 Changes HOPPS - PET Other CPT codes for brain imaging, tumor imaging, positron emission tomography (PET) imaging and PET/CT have been assigned to APC 0308 (Non. Myocardial Positron Emission Tomography (PET) imaging) in 2012 with a national unadjusted rate of $1, 015 This rate is down from the 2011 national unadjusted rate for APC 0308 is $1, 042 and again, this decrease might have negative ramifications for facilities providing these procedures

2012 Changes HOPPS - IMRT The 2012 HOPPS Final Rule reassigns CPT code 77338 (Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan) from APC 0310 to APC 0305 This reassignment to APC 0305 (with a national unadjusted rate of $256. 92) from APC 0310 (with a 2011 national unadjusted rate of $919. 54) represents a decrease of approximately 72% for the code in 2012

2012 Changes HOPPS - IMRT The reduction is made more severe by the fact in 2010 CPT code 77334 (treatment devices, design and construction; complex [irregular blocks, special shields, compensators, wedges, molds or casts]) was replaced by code 77338 Prior to 2010, facilities could report an unlimited number of units for code 77334 and be paid for each device used in a treatment, but 77338 cannot be reported in multiple units, only a single unit of service

2012 Changes HOPPS – Physician Supervision The Final Rule revised the physician supervision rules that apply to hospital outpatient services. The changes now include the following: • The federal Advisory Panel on Ambulatory Payment Classification Groups (Panel) will serve as the independent review body that evaluates individual hospital outpatient therapeutic services and recommends to CMS a supervision level (general, direct or personal) to ensure an appropriate level of quality and safety • CMS will issue decisions based on Panel recommendations through subregulatory guidance • Definitions for personal supervision and general supervision for all hospital outpatient therapeutic services will be added [to the rules]

2012 Changes MPFS The 2012 Medicare Physician Fee Schedule Final (MPFS) Rule where the biggest news by far was the 27. 4% cut in reimbursement mandated by the Sustainable Growth Rate (SGR) formula • This cut is less than the 29. 5% reduction put forth in the 2012 Proposed Rule for the MPFS, but still a major blow to providers in the Part B setting In total, CMS projects total payments under the MPFS in calendar year 2012 will be approximately $80 billion

2012 Changes MPFS - SGR The SGR is the annual growth rate formulary used to establish physician reimbursement under Medicare and there have been 11 times that the SGR has called for a cut since the formula first came into existence – the majority of which have been repealed by legislative action after the release of a Final MPFS Rule

2012 Changes MPFS - SGR President Obama signed legislation in February averting 27. 4% reduction The reprieve is postpones any fee schedule reduction until January 1 st 2013 We will continue to monitor the situation and its potential impact on practice revenues

2012 Changes MPFS – Multiple Procedures In 2012 CMS continues paying for all multiple imaging procedures within an imaging family performed on the same date of service using the multiple imaging composite payment methodology The multiple imaging procedure families do not include nuclear medicine, but do impact CT and MR procedures

2012 Changes MPFS – Multiple Procedures In another area related to multiple imaging procedures, CMS implemented a three-day policy window payment provisions This will pay physicians services at the lower facility rate if they are delivered in a physician office wholly owned and operated by a hospital and provided within three days of a hospital admission

2012 Changes MPFS – PQRI Meaningful use of electronic health records by eligible professionals within the Medicare and Medicaid EHR Incentive Programs will continue per the 2012 Final MPFS Rule For 2012 CMS finalized several requirements related to how groups and individual physicians report to the PQRI A total of 23 measures for reporting include several new groups, such as cardiovascular prevention, dementia, Parkinson's, cataracts and others

Coding Basics Just because there is a code doesn’t mean it will be reimbursed Variables of reimbursement • • Coverage Edits Deductibles and co-pays Prior authorization requirements

2012 Coding Changes – CPT 77470 - Special treatment procedure (e. g. , total body irradiation, hemibody radiation, per oral or endocavitary irradiation) 78580 - Pulmonary perfusion imaging (e. g. , particulate)

2012 Coding Changes – CPT Hepatobiliary imaging code 78223 has been deleted and replaced by two new codes • 78226 --Hepatobiliary system imaging, including gallbladder when present • 78227 --Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed

2012 Coding Changes – CPT Nine existing lung imaging codes, 78584 -78596, have been combined into four new codes • 78579 --Pulmonary ventilation imaging (e. g. , aerosol or gas) • 78582 --Pulmonary ventilation (e. g. , aerosol or gas) and perfusion imaging • 78597 --Quantitative differential pulmonary perfusion, including imaging when performed • 78598 --Quantitative differential pulmonary perfusion and ventilation (e. g. , aerosol or gas), including imaging when performed

2012 Coding Changes – HCPCS A 9584 Iodine I-123 Ioflupane, diagnostic, per study dose, (up to 5 millicuries) - for Da. Tscan® used for striatal dopamine transporter visualization usingle photon emission computed tomography (SPECT) brain imaging

2012 Coding Changes – HCPCS Please call UPPI Reimbursement Support (888 900 2674) for a complete listing of the HCPCS codes used in nuclear medicine

2012 Coding Changes – ICD. 9 -CM code 793. 1 was used to report PET scan performed prior to biopsy for diagnosis of lung cancer in patients with lung masses, solitary pulmonary nodules and multiple pulmonary nodules In 2012 this code was deleted with the addition of two new five digit codes as follows: • 793. 11 - Solitary pulmonary nodule • 793. 19 - Other nonspecific abnormal findings of lung field

Healthcare Reform 2012 The 2012 Final Rule for the MPFS implements parts of the Patient Protection and Affordable Care Act (Healthcare Reform as we lovingly refer to it) including Section 3007 which requires CMS to apply a value modifier comparing the quality of care delivered to the cost of that care, to physician payment rates All physicians and physician groups under the MPFS will be held to the value modifier by 2017

Healthcare Reform 2012 The items relating to the value modifier include quality of care measures (e. g. , cardiovascular and chronic conditions and preventive measures) and cost measures (e. g. , total per capita cost and per capita cost for conditions such as chronic obstructive pulmonary disease, heart failure, diabetes and others)

Healthcare Reform 2012 The law establishes a hospital Value Based Purchasing Program (VBP) offering financial incentives to hospitals to improve the quality of care Hospital performance is required to be publicly reported, beginning with measures relating to heart attacks, heart failure, pneumonia, surgical care, health-care associated infections, and patients’ perception of care • Effective for payments for discharges occurring on or after October 1, 2012

Healthcare Reform 2012 The new law provides incentives for physicians to join together to form “Accountable Care Organizations” These groups allow doctors to better coordinate patient care and improve the quality, help prevent disease and illness and reduce unnecessary hospital admissions ACOs that provide high quality care and reduce costs to the health care system, they can keep some of the money that they have helped save • Effective January 1, 2012

Healthcare Reform 2012 Health care remains one of the few industries that relies on paper records and healthcare reform institutes a series of changes to standardize billing and requires health plans to adopt electronic exchange of health information Electronic Health Records (EHR) will reduce paperwork and administrative burdens, cut costs, reduce medical errors and most importantly, improve the quality of care • First regulation effective October 1, 2012

Q&A

Contact Us Barbara Ossias Reimbursement Revenue Solutions Direct line 301 371 4829 Reimbursement Hotline 1 888 900 2674 bossias@reimbursementrevenuesolutions. com www. reimbursementrevenuesolutions. com