Medicare

ASTRO Joint Letter: C-APC Methodology Impact on Radiation Oncology Services

Medicare Physician Fee Schedule Impact Tool

ASTRO Comments on Virtual Direct Supervision

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 2025
Key Issues focused on:

• MPFS Conversion Factor 
• CY 2025 Clinical Labor Pricing Update Proposals 
• Development of Strategies for Updates to Practice Expense (PE) Data Collection and Methodology 
• Payment for Medicare Telehealth Services under § 1834(m) of the Act 
• Direct Supervision via Use of Two-way Audio/Video Communications Technology 
• Office/Outpatient (O/O) Evaluation and Management (E/M) Visit Complexity Add-on 
• Implementation of Payment for Dental Services Inextricably Linked to Other Specific Covered Services
• New Codes for Biology-Guided Radiation Therapy (BgRT)
• Payment of Radiopharmaceuticals in the Physician Office
• Prostate Cancer Cost Measure Request for Information for Services Addressing Health-Related Social Needs (Community Health Integration (G0019, G0022), Principal Illness Navigation (G0023, G0024), Principal
• Illness Navigation-Peer Support (G0140, G0146), and Social Determinants of Health Risk Assessment (G0136))

ASTRO Comments on 2025 MPFS Proposed Rule
Key comments focused on:

• Payment Rates for Radiation Oncology Services
• Development of Strategies for Updates to Practice Expense (PE) Data Collection and Methodology
• Payment for Medicare Telehealth Services under § 1834(m) of the Act
• Payment of Radiopharmaceuticals in the Physician Office
• Global Surgical Package Proposal
• Request for Information for Services Addressing Health-Related Social Needs (Community Health Integration (G0019, G0022), Principal Illness Navigation (G0023, G0024), Principal Illness Navigation-Peer Support (G0140, G0146), and Social Determinants of Health Risk Assessment (G0136))
• Merit-Based Incentive Payment System (MIPS)
• MIPS Value Pathways (MVPs)
• Alternative Payment Models (APM)
• Requests for Information

MPFS Proposed Rule for calendar year 2025
Key issues focused on:

• MPFS Conversion Factor
• CY 2025 Clinical Labor Pricing Update Proposals
• Development of Strategies for Updates to Practice Expense (PE) Data Collection and Methodology
• Payment for Medicare Telehealth Services under § 1834(m) of the Act
• Direct Supervision via Use of Two-way Audio/Video Communications Technology
• Office/Outpatient (O/O) Evaluation and Management (E/M) Visit Complexity Add-on
• Proposals on Medicare Parts A and B Payment for Dental Services Inextricably Linked to Specific Covered Services
• Payment of Radiopharmaceuticals in the Physician Office
• Request for Information for Services Addressing Health-Related Social Needs
• Health Integration (G0019, G0022), Principal Illness Navigation (G0023, G0024), Principal Illness Navigation-Peer Support (G0140, G0146), and Social Determinants of Health Risk  Assessment (G0136))

ASTRO Comments on 2024 MPFS Proposed Rule
Key comments focused on:

• Payment Rates for Radiation Oncology Services
• Evaluation and Management (E/M) Visit Complexity
• Payment for Medicare Telehealth Services
• Direct Supervision via Use of Two-way Audio/Video Communications Technology
• Payment for Dental Services Linked to Specific Covered Medical Services
• Request for Information (RFI): Drugs and Biologicals which are Not Usually Self-Administered by the Patient, and Complex Drug Administration Coding
• Soliciting Public Comment on Strategies for Updates to Practice Expense Data Collection and Methodology
• Services Addressing Health-Related Social Needs
• Quality Payment Program

MPFS Proposed Rule for calendar year 2024
Key issues focused on:

• MPFS Impact
• Conversion Factor/Target
• Evaluation and Management (E/M) Visit Complexity
• Telephone E/M Services
• Payment for Medicare Telehealth Services Under Section 1834(m) of the Social Security Act
• Direct Supervision via Use of Two-way Audio/Video Communications Technology
• Proposals on Medicare Parts A and B Payment for Dental Services Inextricably Linked to Specific Covered Medical Services
• Soliciting Public Comment on Strategies for Updates to Practice Expense Data Collection and Methodology
• Services Addressing Health-Related Social Needs

MPFS Final Rule for calendar year 2023
Key comments focused on:

• MPFS Impact
• Conversion Factor/Target
• G Codes
• Clinical Labor Pricing Update
• Request for Information on Strategies for Updates to Practice Expense (PE) Data Collection and Methodology
• Determination of Malpractice Relative Value Units (RVUs)
• Rebasing and Revising the Medicare Economic Index
• Proposals and Request for Information on Medicare Parts A and B Payment for Dental Services
• Payment for Medicare Telehealth Services Under Section 1834(M) of the Act
• Request for Information: Medicare Potentially Underutilized Services
• Soliciting Public Comment on Strategies for Improving Global Surgical Package Valuation

MPFS Proposed Rule for calendar year 2023
Key comments focused on:

• MPFS Impact
• Conversion Factor/Target
• Clinical Labor Pricing Update
• Request for Information on Strategies for Updates to Practice Expense Data Collection and Methodology
• Determination of Malpractice Relative Value Units
• Rebasing and Revising the Medicare Economic Index
• Proposals and Request for Information on Medicare Parts A and B Payment for Dental Services
• Payment for Medicare Telehealth Services Under Section 1834(M)
• Request for Information on Medicare Potentially Underutilized Services
• Soliciting Public Comment on Strategies for Improving Global Surgical Package Valuation
• Quality Payment Program

ASTRO Comments on 2022 MPFS Proposed Rule
ASTRO expressed concern about the financial implications this proposed rule will have on radiation oncology practices and urged CMS to work on a more comprehensive and equitable solution to the clinical labor pricing update proposal.

MPFS Proposed Rule for calendar year 2022 
Key comments focused on:

• MPFS Impact
• Clinical Labor Pricing Update
• Conversion Factor/Target
• Direct PE Inputs for Supply and Equipment Pricing (Year Four of Four-year Phase-In)
• Expiration of PHE Flexibilities for Direct Supervision Requirements
• Potentially Misvalued Codes
• Open Payments

Clinical Labor Pricing Update Coalition Letter

Hospital Outpatient Prospective Payment System (HOPPS)

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.

Summaries on annual rules on the Hospital Outpatient Prospective Payment System (HOPPS) regulations:

HOPPS Final Rule for Calendar Year 2025
Key issues focused on:

• Conversion Factor Update 
• Ambulatory Payment Classifications (APC) 
• Comprehensive Ambulatory Payment Classifications (C-APCs) 
• Extension of Virtual Direct Supervision through December 31, 2025 
• Two-Times Rule Exception 
• Brachytherapy Sources 
• Changes to the Review Timeframes for the Hospital Outpatient Department (OPD) Prior Authorization Process 
• Payment Policy for Radiopharmaceuticals 
• Diagnostic Radiopharmaceuticals Separate Payment 
• Add-on Payment for Radiopharmaceutical Technetium-99m (Tc-99m) 
• Cancer Hospital Payment Adjustment 
• Biology Guided Radiation Therapy (BgRT) 
• Applications Received for Device Pass-Through Status for CY 2025 
• New Technology APCs 

ASTRO Comments on 2025 HOPPS Proposed Rule
Key comments focused on:

• Comprehensive Ambulatory Payment Classifications (C-APCs)
• Brachytherapy Sources
• Changes to the Review Timeframes for the Hospital Outpatient Department (OPD) Prior Authorization Process
• Diagnostic Radiopharmaceuticals Separate Payment
• Add-on Payment for Radiopharmaceutical Technetium-99m (Tc-99m)
• Procedures Assigned to New Technology APCs for CY 2025 – Biology Guided Radiation Therapy
• All-Inclusive Rate (AIR) Add-On Payment for High-Cost Drugs Provided by Indian Health Service and Tribal Facilities

HOPPS Proposed Rule for calendar year 2025
Key issues focused on:

• Proposed Conversion Factor Update
• Ambulatory Payment Classifications (APC)
• Comprehensive Ambulatory Payment Classifications (C-APCs)
• Extension of Virtual Direct Supervision of Cardiac Rehabilitation (CR), Intensive Cardiac Rehabilitation (ICR), Pulmonary Rehabilitation (PR) Services and Diagnostic Services Furnished to Hospital Outpatients through December 31, 2025
• Two-Times Rule Exception
• Brachytherapy Sources
• Changes to the Review Timeframes for the Hospital Outpatient Department (OPD) Prior Authorization Process
• Diagnostic Radiopharmaceuticals Separate Payment
• Add-on Payment for Radiopharmaceutical Technetium-99m (Tc-99m)
• Cancer Hospital Payment Adjustment
• Payment Policy for Radiopharmaceuticals
• New HCPCS Codes Effective April, 2024
• Applications Received for Device Pass-Through Status for CY 2025
• Proposed New Technology APCs
• Cross-Program Proposals for the Hospital Outpatient Quality Reporting (OQR), Rural Emergency Hospital Quality Reporting (REHQR), and Ambulatory Surgical Center Quality Reporting (ASCQR) Programs
• Hospital Outpatient Quality Reporting (OPQ) Program

ASTRO Comments on 2024 HOPPS Proposed Rule
Key comments focused on:

• Comprehensive Ambulatory Payment Classifications (C-APCs)
• Proposed OPPS Payment for Dental Services
• Solicitation of Comments on OPPS Packing Policy for Diagnostic Radiopharmaceuticals
• Health Equity – Addressing the Impact of APC Payment Methodology on Beneficiaries

HOPPS Proposed Rule for calendar year 2024
Key issues included:

• Proposed Conversion Factor Update
• Proposed Use of Most Updated Claims Report Data for Rate Setting
• Ambulatory Payment Classifications (APC)
• Comprehensive Ambulatory Payment Classifications (C-APCs)
• Two-Times Rule Exception
• Brachytherapy Sources
• Hospital Outpatient Quality Reporting (OPQ) Program
• Proposed OPPS Payment for Dental Services
• Cancer Hospital Payment Adjustment
• Proposed OPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals
• Applications Received for Device Pass-Through Status for CY 2023
• Proposed New Technology APCs
• Health Equity
• Rural Emergency Hospital Quality Reporting (REHQR) Program

HOPPS 2023 Final Rule Summary 
Key comments focused on:

• Conversion Factor Update
• Ambulatory Payment Classifications (APC)
• Comprehensive Ambulatory Payment Classifications (C-APCs)
• Two-Times Rule Exception
• Brachytherapy Sources
• OPPS Payment for Software as a Service
• OPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals
• New HCPCS Codes Effective July 1, 2022
• Applications Received for Device Pass-Through Status for CY 2023
• Proposed New Technology APCs
• Cancer Hospital Payment Adjustment
• Health Equity

Final Rule for calendar year 2023
Key comments focused on:

• 340B
• Comprehensive Ambulatory Payment Classifications (C-APCs)
• Two-Times Rule Exception
• APC Classification of CPT Code 76145, Medical physics dose evaluation for radiation exposure that exceeds institutional review threshold, including report
• Brachytherapy Sources
• HOPPS Payment for Software as a Service 
• Proposed HOPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals
• Health Equity

Proposed Rule for calendar year 2023
Key issues included:

• Proposed Conversion Factor Update
• Proposed Use of June 2020 Cost Report and CY 2021 Claims Report Data effort CY 2023 OPPS and ASC Payment System Rate Stetting Due to the PHE
• Ambulatory Payment Classifications (APC)
• Comprehensive Ambulatory Payment Classifications (C-APCs)
• Two-Times Rule Exception
• Brachytherapy Sources
• OPPS Payment for Software as a Service 
• Proposed OPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals
• New HCPCS Codes Effective July 1, 2022
• Applications Received for Device Pass-Through Status for CY 2023
• Proposed New Technology APCs
• Cancer Hospital Payment Adjustment
• Health Equity
• Rural Emergency Hospital Quality Reporting (REHQR) Program
• Rural Emergency Hospital (REH) Payment Policy

ASTRO Comments on 2022 HOPPS Proposed Rule
ASTRO expressed concerns with the Comprehensive Ambulatory Payment Classification (C-APC) methodology and provided input on CMS’ request for information on ways to advance health equity.

Proposed Rule for calendar year 2022
Key comments focused on:

• Proposed Conversion Factor Update
• Ambulatory Payment Classifications (APC)
• Ambulatory Payment Classifications (C-APC)
• Two-Times Rule Exception
• Brachytherapy Sources
• New HCPCS Codes Effective July 1, 2021
• Proposed New Technology APCs
• Cancer Hospital Payment Adjustment
• Health Equity
• Hospital Price Transparency Fines

Inpatient Prospective Payment System (IPPS)

The Medicare Inpatient Prospective Payment System (IPPS) was introduced by the federal government as a way to change hospital behavior through financial incentives that encourage more cost-efficient management of medical care. Medicare sets forth a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. Under the IPPS, hospitals are paid a pre-determined rate for each Medicare admission categorized into a diagnosis-related group (DRG) on the basis of clinical information. Regardless of the actual services provided, each DRG has a flat payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG.

CMS publishes a Proposed and a Final IPPS Rule each year that addresses certain provisions 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 the services that radiation oncologists provide.

Summaries of annual rules on the Inpatient Prospective Payment System (IPPS) regulations:

Proposed rule for calendar year 2026

• New Technology Add-On Payments (NTAP) for New Services and Technologies
• Proposed Changes to Specific MS-DRG Classifications
• Proposed Discontinuation of the Low-Wage Hospital Policy
• End of Medicare-Dependent, Small Rural Hospital Designation
• Proposed Changes to the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
• Proposed Update to the IPPS Labor-Related Share
• Hospital Readmission Reduction Program
• Hospital Inpatient Quality Reporting (IQR) Program
• Medicare Promoting Interoperability Program

Proposed rule for calendar year 2025

• Intraoperative Radiation Therapy (IORT)
• Proposed Changes to the Hospital Wage Index for Acute Care Hospitals
• Proposed Continuation of the Low-Wage Hospital Policy
• Proposed Changes to the PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
• Hospital Inpatient Quality Reporting (IQR) Program
• New Technology Add-On Payments (NTAP) for New Services and Technologies
• CMS Specialty Care Strategy: TEAM Model
• Social Determinants of Health Diagnosis (SDOH) Codes

Final rule for calendar year 2024

• New Technology Add-On Payments (NTAP) for New Services and Technologies for FY 2024
• Continuation of the Low Wage Index Hospital Policy
• Permanent Cap on Wage Index Decreases and Budget Neutrality Adjustment
• Modification to the Rural Wage Index Calculation Methodology
• PPS-Exempt Cancer Hospital Quality Reporting Program (PCHQR)
• Hospital Inpatient Quality Reporting (IQR) Program
• Medicare Promoting Interoperability Program
• Request for Information on Challenges Faced by Safety-Net Hospitals
• Changes to the Severity Level Designation for Z Codes Describing Homelessness

Proposed rule for calendar year 2024

• New Technology Add-On Payments (NTAP) for New Services and Technologies
• Proposed Continuation of the Low Wage Index Hospital Policy
• Permanent Cap on Wage Index Decreases and Budget Neutrality Adjustment
• Proposed Modification to the Rural Wage Index Calculation Methodology
• PPS-Exempt Cancer Hospital Quality Reporting Program (PCHQR)
• Hospital Inpatient Quality Reporting (IQR) Program
• Medicare Promoting Interoperability Program
• Request for Information on Challenges Faced by Safety-Net Hospitals
• Proposed Changes to the Severity Level Designation for Z Codes Describing Homelessness

Final rule for calendar year 2023

• New Technology Add-On Payments (NTAP) for New Services and Technologies for 2023
• 2021 MedPAR data and FY 2020 HCRIS for analyzing MS-DRG changes and determining MS-DRG relative weights
• Reclassification of laser interstitial thermal therapy’s (LITT) MS-DRG
• Permanent cap on wage index increases
• Low Wage Index Value Hospital Policy
• Modifications to the PPS-Exempt Cancer Hospital Quality Reporting Program and Medicare Promoting Interoperability Program

Proposed rule for calendar year 2023

• New Technology Add-On Payments (NTAP) for New Services and Technologies for 2023
• Reversion to historical two-year data periods for determining MS-DRG rate changes
• Reclassification of laser interstitial thermal therapy’s (LITT) MS-DRG
• Permanent cap on wage index increases
• Modifications to the PPS-Exempt Cancer Hospital Quality Reporting Program and Medicare Promoting Interoperability Program
• Principles for measuring health care quality disparities across CMS quality programs

Final Rule for calendar year 2022

• New Technology Add-On Payments (NTAP) for New Services and Technologies for 2022
• 2019 MedPAR data and FY 2018 HCRIS file for analyzing MS-DRG changes and determining MS-DRG relative weights
• Repeal of Private Payer MS-DRG Relative Weight Data to Inform Future Medicare Rates
• Low Wage Index Value Hospital Policy Maintained
• Closing the Health Equity Gap – Request for Information
• PPS-Exempt Cancer Hospital (PCH) Quality Reporting (PCHQR) Program
• Medicare Promoting Interoperability Program
• Hospital Inpatient Quality Reporting (IQR) Program

Proposed Rule for calendar year 2022

• A request for information on closing the health equity gap
• New Technology Add-On Payments (NTAP) for new services and technologies for FY 2022
• Repeal of private payer MS-DRG relative weight data to inform future Medicare rates
• Continuation of the Low Wage Index Value Hospital Policy
• PPS-Exempt Cancer Hospital Quality Reporting Program
• Medicare Promoting Interoperability Program
• Hospital Inpatient Quality Reporting Program

• ASTRO Comments on CMS Proposed Rule for the Medicare Program (2/23)
  In December 2022, CMS released a proposed rule for the Medicare Program for contract year 2024 with provisions aimed at improving health equity and the utilization management process for Medicare Advantage (MA) plans. ASTRO is in full support of the proposed rule with provisions such as requiring MA plans to comply with National Coverage Determinations (NCD), Local Coverage Determinations (LCD) and traditional Medicare regulations highlighting the points for which ASTRO has advocated. We are pleased to see CMS act towards MA reform.
• ASTRO summary on CMS proposed rule to reduce prior authorization burden (12/22)
  On Tuesday, December 6, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that sets a three-year timeline for implementing prior authorization standards to reduce burden and improve patient care. After years of ASTRO advocacy regarding the inappropriate use of prior authorization, CMS is responding with a series of policy proposals that standardize its use, including response timeframes, clear coverage decision communications, and public reporting on frequency of approvals, denials and appeals. The rule also seeks to improve health information exchange, and facilitate patient, provider and payer access to information in health records.
• ASTRO Responds to CMS Request for Information on the Medicare Advantage Program (8/22)
  On August 1, 2022, CMS released a Request for Information on various aspects of the Medicare Advantage (MA) program including the advancement of health equity, expanding access to coverage and care, supporting affordability and sustainability, and prior authorization.
• ASTRO issues comments in response to the Enhancing Oncology Model (7/22)
  On June 27 CMS issued the Enhancing Oncology Model (EOM). The EOM seeks to extend many of the provisions of the Oncology Care Model, such as the inclusion of all Part A and Part B services, including radiation oncology, within a six-month episode of care. ASTRO’s summary of the model request for applications outlines the parameters if EOM including the addition of two risk options and a reduction in the Monthly Enhanced Oncology Services (MEOS) payment. ASTRO’s letter highlights the potential unintended consequences of including radiation therapy in a broader episode of care due to its relative cost within a total cost of care episode, which may inappropriately reduce referrals and overall utilization.
• ASTRO Comments to CMS on 2023 IPPS Proposed Rule (6/22)
  ASTRO weighed in on the CMS proposals to reclassify laser interstitial thermal therapy’s MS-DRG and to return to using the most recent data available for analyzing MS-DRG changes and determining relative weights. Additionally, ASTRO supported the proposal to adopt a permanent cap on wage index decreases and provided input on proposals around the Medicare Promoting Interoperability and Hospital Inpatient Quality Reporting Programs. Finally, ASTRO gave feedback on the requests for information for Social Determinants of Health diagnosis codes and the current assessment of climate change impacts on outcomes, care and health equity.
• ASTRO Comments to HHS Request for Information related to Electronic Prior Authorization (3/22)
  On January 24, 2022, the Department of Health and Human Services (HHS) issued a Request for Information regarding electronic prior authorization standards. ASTRO submitted comments reflecting previously stated concerns about prior authorization, as well as reference to ASTRO’s work with CodeX, a member driven HL7FHIR-based interoperability program, that is using mCode (minimal Common Oncology Data Elements) to create new workflow patterns, including standardized prior authorization applications.
• ASTRO Responds to MIPS Prostate Cost Measure Proposal (4/22)
  ASTRO expressed concerns in comments to CMS and Acumen LLC about a proposed prostate cancer measure for the Merit-based Incentive Payment System (MIPS). Since the Medicare Access and CHIP Reauthorization Act (MACRA) was enacted in 2015, CMS and Acumen have been developing cost measures for MIPS. ASTRO reviewed the prostate cancer proposal and provided comments in response indicating that the measure would be complicated due to the lack of staging found in claims data, as well as the variety of different types of treatments involved. Rather than pursue prostate cancer, ASTRO recommended that the CMS/Acumen team consider using the existing lumpectomy/partial mastectomy cost measure, which is focused on surgical care, as a starting point for measuring the cost of RT and chemo related to breast cancer treatment.
• ASTRO Comments on 2022 IPPS Proposed Rule (6/21)
  ASTRO expressed support for the extension of new technology add on payments for a technology involving radiation treatment delivery; weighed in on CMS’ request for information on closing the health equity gap in CMS hospital quality programs; applauded the Agency’s proposal to repeal the market-based data collection and market-based MS-DRG relative weight methodology; expressed our concerns about the proposed methodology for the Low Wage Index Hospital Policy; and commented on the PPS-Exempt Cancer Hospital Quality Reporting Program (PCHQR), Medicare Promoting Interoperability Program and the Hospital Inpatient Quality Reporting Program.