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

ASTRO 2018 MPFS Final Rule Summary

ASTRO 2018 HOPSS Final Rule Summary

ASTRO 2018 HOPSS Final Rule Comments Letter

ASTRO 2018 QPP Final Rule Summary

ASTRO 2018 QPP Final Rule Comments Letter

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 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.

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

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)

Proposed Rule for calendar year 2018
Key comments focused on:

• Comprehensive APC Methodology
  • C-APC 5627 - Level 7 Radiation Therapy
  • C-APCs 5113, 5165, 5302, 5341, and 5414 - Brachytherapy Insertion  
• Composite APC 8001 LDR Prostate Brachytherapy
• APC 5625 Level 5 Radiation Therapy – Proton Therapy
• Expansion of Excepted Off-Campus Provider Based Department Services
• Enforcement Instruction for Supervision of Outpatient Therapeutic Services in
• Critical Access Hospitals (CAHs) and Certain Small Rural Hospitals
• Ambulatory Surgical Center (ASC) Payment Reform
• OP-33: External Beam Radiotherapy for Bone Metastases (NQF# 1822)

Final Rule for calendar year 2017 (12/30)
Key comments focused on:

• Comprehensive APCs (C-APCs)
• Ambulatory Payment Classifications (APCs)
• Hospital Outpatient Quality reporting Program
• Electronic Health Records Incentive Program 

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

• Comprehensive APCs
• Therapeutic Radiation Treatment Preparation
• Advisory Panel on Hospital Outpatient Payment

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

• General Comments: C-APCs and Restructuring APCs
• CPT Code 77301 IMRT Planning and CPT Code 77290 Simulation 
• Brachytherapy 
• SRS/SBRT
• Outpatient Quality Reporting 

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

• General Comments: C-APCs and Restructuring APCs
• CPT code 77301 IMRT Planning and CPT code 77290 Simulation
• Brachytherapy
• SRS/SBRT
• Radiation Therapy Devices
• Outpatient Quality Reporting-OP-33 External Beam Radiotherapy for Bone Metastases 

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

• CMS Approval of New 2015 Radiation Oncology CPT Codes
• Comprehensive APC Policy for SRS & IORT
• APC 0066, SBRT (CPT Code 77373)
• Proton Beam Therapy (77520-77525)
• Low Dose Rate (LDR) Prostate Brachytherapy Composite APC 8001
• Insert Uteri Tandem/Ovoids (CPT Code 57155)
• APC 0304 Level I Therapeutic Radiation Treatment Preparation
• Understanding the Different Resource Costs among Traditional Office, Facility and Off-campus Provider-based Setting

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

• Comprehensive APC Policy (SRS and IORT)
• Stereotactic Body Radiation Therapy (SBRT) (77373)
• Proton Beam Therapy (77520-77525)
• Low Dose Rate (LDR) Prostate Brachytherapy Composite APC
• Proposal to Modify the Current Process for Accepting New and Revised CPT Codes that Are Effective January 1
• Insert Uteri Tandem/Ovoids (57155)
• Understanding Different Resource Costs among Traditional Office, Facility and Off-campus Provider-based Settings

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

• Changes to Packaged Items and Services
• Stereotactic Radiosurgery (SRS) Services (APCs 0066 and 0067)
• Intraoperative Radiation Therapy (IORT) Related Services (APCs 0028 and 0065)
• Proton Beam Therapy (APCs 0664 and 0667)
• Interstitial Radiation Source Application (APC 0312)
• Supervision of Hospital Outpatient Therapeutic Services

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

• Variety of problems with the data used for rate-setting
• Q1 conditional packaging proposal
• Stereotactice Radiosurgery (SRS) and Stereotactice Body Radiation Therapy (SBRT) (APCs 0066 and 0067)
• Proton Beam Radiation Therapy (APC 0064 and 0067)
• Intraoperative Radiation Therapy (IORT) (APC 0065)
• Supervision of Hospital Outpatient Therapeutic Services

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.

Final Rule for calendar year 2020
Key comments focused on:

• New Technology Add-On Payments (NTAP) for New Services and Technologies for 2020
• Evaluation of Substantial Clinical Improvement Criterion for IPPS NTAP and OPPS Transition Pass-Through Payments for Devices
• New NTAP Pathway for Transformative New Devices
• Medicare Wage Index Disparities
• IPPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
• Hospital Inpatient Quality Reporting (IQR) Program

Proprosed Rule for calendar year 2020
Key comments focused on:

• New Technology Add-On Payments (NTAP) for New Services and Technologies for 2020
• Evaluation of Substantial Clinical Improvement Criterion for IPPS NTAP and OPPS Transition Pass-Through Payments for Devices
• Medicare Wage Index Disparities

• ASTRO comments on 2020 MPFS Proposed Rule(9/19)
• ASTRO comments on 2020 HOPPS Proposed Rule(9/19)
• ASTRO comments on 2020 IPPS Proprosed Rule (6/19)
  ASTRO expressed support for New Technology Add-On Payments (NTAP) for three technologies involving radiation therapy; provided guidance regarding modifications to the "substantial clinical improvement" criterion associated with NTAP; and commented on proposed modifications to NTAP payments, as well as the Medicare wage index, and various IPPS quality measures and interoperability requirements.
• ASTRO urges CMS to retain G Codes during value based payment transition (2/19)
• ASTRO comments on "Patients over Paperwork" listening session
• ASTRO Comments on MIPS APM Proposed Rule (6/16)
  ASTRO outlined concerns regarding changes to radiation oncologists under the proposed Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA is a comprehensive system of payment incentives aimed to restructure CMS reimbursement models through Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). Changes could be implemented as early as January 2017.  
• ASTRO signs letter with AMA regarding proposed changes under MACRA (6/16) 
  ASTRO expressed unified concerns with several other medical specialty groups regarding the proposed rule set forth by CMS. The proposed rule represents dramatic changes in the way Medicare will pay physicians, with significant impact to all clinicians. 
• ASTRO Provides Feedback on CMS Episode Groups (3/16)
  The Episode Groups RFI sought comments on using episode groups to measure and compare physician resource use in treating Medicare patients in the Merit-based Payment Incentive System (MIPS) and Alternative Payment Models (APMs). 
• ASTRO Comments on CMS Quality Measures Development Plan (3/16)
  The Quality Measures Development Plan draws on measures and strategies from existing quality programs to develop measures for implementation in MIPS and APMs.
• ASTRO Supports 2015 Hardship Exception (10/15)
  Letter supporting Rep. Price's bill for a blanket 2015 hardship exception for providers unable to meet the 90-day reporting period. 
• ASTRO Supports Delay of Meaningful Use Stage 3 (10/15)
  Letter urging Congress to delay Stage 3 and rehaul and refocus the Meaningful Use program. 
• ASTRO Comments on 2015-2017 Meaningful Use Modifications Proposed Rule (6/15)
  ASTRO supported more flexibility in the Meaningful Use program from 2015 through 2017, until implementation and finalization of requirements for the Merit-Based Incentive Payment System (MIPS). 
• ASTRO Comments on Meaningful Use Stage 3 Proposed Rule (5/15)
  ASTRO expressed continued concern that Meaningful Use objectives and measures makes it difficult for radiation oncologists to participate in the program, and that there should be greater flexibility in the program. 
•  ASTRO Supports Interoperability Requirements for Certified EHRs (1/15)
  Requesting the Office of the National Coordinator (ONC) to develop standards and guidance to support data exchange. 
• ASTRO Supports Interoperability Through 21st Century Cures Initiative (1/15)
  Urging Congress to support an ONC mandate to require greater interoperability between EHRs and between EHRs and clinical data registries. 
• 2014 Meaningful Use Proposed Rule Comments
  ASTRO provided comments to CMS supporting flexibility in the Meaningful Use program for 2014 and beyond. 
• ASTRO Comments on CMMI RFI on Outpatient Specialty Care (4/14)
  ASTRO provided written comments to CMS on developing episode-based payment models for outpatient specialty care.  
• ASTRO Comments on Public Reporting on Physician Compare (3/14)
  ASTRO provided written comments on questions raised by CMS on the future of public reporting on Physician Compare, a CMS website to help Medicare beneficiaries identify and select providers. 
• CMS Quality Strategy Comments (1/14)
  ASTRO submitted comments on how its quality initiatives align with the mission and goals of the CMS Quality Strategy.
• Request for Feedback on Physician Compare Search Functionality (1/14)
  ASTRO provided input on enhancing the Physician Compare website's search functionality for radiation oncologists.