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Medicare

Advocating to the Centers for Medicare and Medicaid Services (CMS) is a key activity of the ASTRO Health Policy Department conducted on behalf of ASTRO members and the patients they serve. ASTRO's key areas of focus include Medicare reimbursement, coverage, payment reform and coding policies.

Downloadable Resources

Medicare Physician Fee Schedule (MPFS)

Medicare uses the Medicare Physician Fee Schedule (MPFS) to reimburse for physician services. Payment rates for an individual service are based on three components: Relative Value Units (RVUs) (physician work, practice expense and malpractice), the physician conversion factor (CF) and geographic practice indices (GPCIs). To determine a payment rate the three separate RVUs are adjusted by the corresponding GPCI. The sum of the geographically adjusted RVUs is multiplied by a dollar CF. The CF is updated on an annual basis according to a formula specified by statute.

CMS publishes a Proposed and a Final MPFS Rule each year that addresses certain provisions and changes to Medicare Part B payment policy. ASTRO submits comment letters to CMS on those issues related to radiation oncology to advocate for fair and accurate reimbursement for the services that radiation oncologists provide.

Summaries of the annual rules on the Medicare Physician Fee Schedule (MPFS).

MPFS Final Rule for calendar year 2020
Key comments focused on:

MPFS Impact
Conversion Factor/Target
Conventional Treatment Delivery, IMRT and Image Guidance Codes
Direct PE Inputs for Supply and Equipment Pricing – Year Two of Four Year Phase In
CPT Code 55874
Evaluation and Management Code (E/M) Modifications
E/M Add-on Codes
Physician Supervision Requirements
Quality Payment Program

MPFS Proposed Rule for calendar year 2020
Key comments focused on:

MPFS Impact
Conversion Factor/Target
Retention of G codes (G6001-G6015)
Direct PE Inputs for Supply and Equipment Pricing – Year Two of Four Year Phase In
Evaluation and Management Code (E/M) Modifications
Physician Supervision Requirements
Calculation of GPCI and Malpractice RVUs
Quality Payment Program

MPFS QPP Final Rule for calendar year 2019
Key comments focused on:

Potential Alternative Payment Model for Radiation Therapy
Update to Direct Practice Expense Inputs for Supply and Equipment Pricing
Evaluation and Management Code (E/M) Modifications
MIPS Clinician Eligibility
MIPS Determination Period
MIPS Performance Categories
Qualified Clinical Data Registry
Alternative Payment Models

Proposed Rule for calendar year 2019
Key comments focused on:

Update to Direct Practice Expense Inputs for Supply and Equipment Pricing
Evaluation and Management Code (E/M) Modifications
MIPS Scoring Methodology
Appropriate Use Criteria for Advanced Diagnostic Imaging
MIPS Clinician Eligibility
MIPS Determination Period
Application of MIPS Bonus Points
Virtual Groups
Performance Category Measures, Weights, Performance Periods and Scoring
Qualified Clinical Data Registry
Alternative Payment Models
Improving Healthcare Price Transparency

Final Rule for calendar year 2018

Please Note: The 2018 MPFS final rule was issued without an official comment period.

Proposed Rule for calendar year 2018
Key comments focused on:

CMS Approach to RUC Recommended Values
- Radiation Oncology Conventional Treatment delivery, IMRT & IGRT codes
Valuation of Specific Codes
- Radiation Treatment Planning - CPT Codes 77261, 77262 & 77263
- Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed - CPT Code 55X87
- Superficial Radiation Treatment Planning and Management Related Services - GRRR1
2018 Identification and Review of Potentially Misvalued Services
Technical Corrections for CY 2018 CMS Time File
Separate Payment for High Cost Medical Supplies
Pre-service Clinical Labor for 0-Day and 10-Day Global Services
Obtain Vital Signs Clinical Labor
Calculation of Malpractice RVUs
Proposed Payment Rates under the MPFS Schedule for Nonexcepted Items and Services Furnished by Nonexcepted Off-Campus Provider-Based Departments of a Hospital
MACRA Patient Relationship Categories and Codes
CMS Request for Information on Flexibilities and Efficiencies
2018 MPFS Proposed Rule Quality Provisions

Final Rule for calendar year 2017 (12/30)

Please Note: The 2017 MPFS final rule was issued without an official comment period. In the final rule, CMS expressed concern and sought comment regarding the time and work values associated with Interstitial Radiation Source Codes 77778 and 77790. ASTRO’s comment letter seeks to address the Agency’s concern.

Proposed Rule for calendar year 2017 (9/16)
Key comments focused on:

Valuation of Specific Codes
- Radiation Treatment Devices - CPT Codes 77332, 77333, & 77334
- Special Radiation Treatment - CPT Code 77470
- Interstitial Radiation Source Codes - CPT Codes 77778 & 77790
- Radiation Treatment Delivery, IMRT, and IGRT G Codes
Moderate Sedation
Methodology for Proposing Work RVUs
Potentially Misvalued Codes
- PACS Workstation
- Validating RVUs of Potentially Misvalued Codes
Collecting Data on Resources Used in Furnishing Global Services

Final Rule for calendar year 2016 (12/15)
Key comments focused on:

Radiation Treatment Delivery and Image-Guided Radiation Therapy (IGRT)
Equipment Utilization Rate Assumption for Linear Accelerators
Interstitial Radiation Source Codes - CPT Codes 77778 and 77790
Superficial Radiation Treatment Delivery - CPT Code 77401
Radiation Therapy Centers

Proposed Rule for calendar year 2016 (9/15)
Key comments focused on:

Treatment Delivery and Image-Guided Radiation Therapy (IGRT)
Potentially Misvalued Services
Superficial Radiation Treatment Delivery (CPT 77401)
High Dose Radiation (HDR) Brachytherapy
Recommended Items that are not Direct PE Inputs
Phase-In of Significant RVU Reductions
Target for Relative Value Adjustments for Misvalued Services
Valuation and Code of Global Packages
Medicare Reimbursement for Advance Care Planning
Incident to Billing
Open Payments
Self-Referral
Alternative Payment Models
Merit-Based Incentive Payment System
Physician Quality Reporting System
Physician Compare Website

Final Rule for calendar year 2015 (1/15)
Key comments focused on:

Radiation Treatment Vault
Radiation Therapy Codes
Isodose Calculations with Isodose Planning Bundle (CPT 77316)
Radiation Treatment Delivery (CPT Code 77373)
High-dose-rate Brachytherapy (CPT Codes 77785, 77786,77787)
Radiation Therapy Dose Plan (CPT 77300), Teletherapy Isodose Plan Simple (CPT 77306)
Hyperthermia (CPT Code 77600)
77326-77328-Substitution for PACS Input
77263, 77334-Identified as potentially misvalued codes
77293 PE Input Correction
Understanding the Different Resource Costs among Traditional Office, Facility and Off-campus Provider-based Settings
Reports of Payments or Other Transfers of Value to Covered Recipients (Open Payments)
Physician Quality Reporting System
Physician Compare Website
Value-Based Payment Modifier

Proposed Rule for calendar year 2015 (8/14)
Key comments focused on:

Radiation Treatment Vault
Transparency, Modifications to Valuing New, Revised and Potentially Misvalued Codes
CPT Codes Identified as Potentially Misvalued Codes(77263,77334)
Deletion of G-Codes for Stereotactic Radiosurgery Services(SRS)(77372-77373)
Substitution for PACs Input(77326-77328)
Practice Expense Input Correction(+77293)
Reports of Payments or Other Transfers of Value to Covered Recipients
Maintenance Factor Assumption
Collection of Data to Validate Physician Fee Schedule PERVUs
Understanding Different Resource Costs among Traditional Office, Facility and Off-Campus Provider-based Settings
Physician Quality Reporting System
Physician Compare Website
Physician Value-Based Payment Modifier

Final Rule for calendar year 2014 (1/14)
Key comments focused on:

Using Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Rates in Developing PE RVUs
Adjusting RVUs to Match PE Share of the Medicare Economic Index (MEI)
Brachytherapy Services (77785-77787) Experiencing Unsustainable Reductions
Respiratory Management Simulation (+77293)
Invoice Pricing
Ultrasound Guidance Codes Proposed as Potentially Misvalued (76950, 76965)
Direct PE Inputs for Stereotactic Radiosurgery (SRS) Services (CPT Codes 77372 and 77373)
Radiation oncology: Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services (CPT Code 77301)
Table 29 CY 2014 Interim Final Codes with Direct PE Input Recommendations Accepted with Refinements
Anomalous Supply Inputs
Physician Quality Reporting System (PQRS)
Qualified Clinical Data Registries
Electronic Health Records Incentive Program
Physician Compare Website

Proposed Rule for calendar year 2014 (9/13)
Key comments focused on:

Using OPPS and ASC rates in developing PE RVUs
Revising the Medicare Economic Index (MEI).
Direct PE inputs for Stereotactic Radiosurgery (SRS) services (CPT Codes 77372 and 77373)
Price adjustment for laser diode
Validating RVUs of potentially misvalued codes
Medicare coverage of items and services in FDA Investigational Device Exemption (IDE) clinical studies - revision of Medicare coverage
Proposed changes to the criteria for satisfactory reporting of individual quality measures via registry for individual eligible professionals for the 2014 PQRS incentive
Physician Value-Based Payment Modifiers
Physician Compare website

Hospital Outpatient Prospective Payment System (OPPS)

Physicians who provide services to Medicare beneficiaries while practicing in a hospital outpatient setting are reimbursed for the professional component of that service through the Medicare Physician Fee Schedule. However, the hospital is reimbursed for the technical component associated with that procedure through the hospital outpatient prospective payment system (OPPS). All services paid under OPPS are classified into groups called Ambulatory Payment Classifications, or APCs, each of which have an established payment rate. Services in each APC are similar clinically and in terms of the resources they require.

CMS publishes a Proposed and a Final OPPS rule each year that addresses certain statutory requirements and changes associated with this payment system. ASTRO submits comment letters to CMS on those issues related to radiation oncology to advocate for fair and accurate reimbursement for services radiation oncologists provide in the outpatient hospital setting.

Comments on annual rules on the Hospital Outpatient Prospective Payment System (HOPPS) regulations.

Final Rule for calendar year 2020
Key comments focused on:

Ambulatory Payment Classifications (APC)
Comprehensive Ambulatory Payment Classifications (C-APCs)
General Supervision Requirements Expanded to All Hospital Outpatient Therapeutic Services
Two-Times Rule Exception
Brachytherapy Sources
Proposed Drugs and Biologicals with New or Continuing Pass-Through Payment Status
Proposal to Fast-Track Device Pass-Through Payment for Transformative New Devices
Evaluation of Substantial Clinical Improvement Criterion for Transitional Pass-Through Payments for Devices

Proposed Rule for calendar year 2020
Key comments focused on:

Ambulatory Payment Classifications (APC)
Comprehensive Ambulatory Payment Classifications (C-APCs)
Two-Times Rule Exception
Brachytherapy Sources
Proposed Drugs and Biologicals with New or Continuing Pass-Through Payment Status
Proposal to Fast-Track Device Pass-Through Payment for Transformative New Devices
Evaluation of Substantial Clinical Improvement Criterion for Transitional Pass-Through Payments for Devices
Supervision Policy for Rural Practices
Comment Solicitation on Cost Reporting, Maintenance of Hospital Chargemasters, and Related Medicare Payment Issues
Making Public Consumer-Friendly Standard Charges for a Set of ‘Shoppable Services’
HOPPS Quality Reporting Requirements

Final Rule for calendar year 2019
Key comments focused on:

Comprehensive APC Methodology
New Device Pass-Through Application - SpaceOAR®
Method to Control Unnecessary Increases in Volume of Outpatient Services
Expansion of Excepted Off-Campus Provider Based Department Services
OP-33: External Beam Radiotherapy for Bone Metastases (NQF# 1822)

Proposed Rule for calendar year 2019
Key comments focused on:

Comprehensive APC Methodology
New Device Pass-Through Application - SpaceOAR®
Method to Control Unnecessary Increases in Volume of Outpatient Services
Expansion of Excepted Off-Campus Provider Based Department Services
OP-33: External Beam Radiotherapy for Bone Metastases (NQF# 1822)

Final Rule for calendar year 2018
Key comments focused on:

Comprehensive APCs (C-APCs)
- C-APCs 5165, 5302, and 5414 - Brachytherapy Insertion
Ambulatory Payment Classifications (APCs)