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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.

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.

Comment letters submitted to CMS on the Medicare Physician Fee Schedule (MPFS).  

Final Rule for calendar year 2014 (1/27)

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; and
  • 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.

Final Rule for calendar year 2013 (12/12)
Key comments focused on:

  • CPT code 77418 IMRT treatment delivery.
  • CPT code 77373 SBRT treatment delivery.
  • CPT code 77301 Radiotherapy dose plan IMRT.
  • CPT code 77336 Physics consult.
  • Table 8 – Codes with stand alone procedure time.
  • Interest rate assumption.
  • Oncology measures group for PQRS 2013 and beyond.

Proposed Rule for calendar year 2013 (9/12)
Key comments focused on:

  • Reduction in procedure time for IMRT and SBRT treatment.
  • Radiation oncology services identified for review – Table 9.
  • Updated interest rate assumption.
  • Public nomination of potentially misvalued code – CPT Code 77336, Medical physics consult.
  • Oncology measures group for PQRS 2013.
  • Proposed reporting criteria for satisfactory reporting of measures groups for PQRS 2013.
  • Proposed criteria for satisfactory reporting for the 2015 and 2016 PQRS payment adjustments.
  • PQRS Group Reporting Option (GPRO).

Final Rule for calendar year 2012 (1/12)
Key comments focused on:

  • Practice Expense Inputs for CPT code 77418, Radiation tx delivery, IMRT.
  • Nomination of Potentially Misvalued Code – CPT code 77336, Radiation physics consult.
  • Incorporation of New Measures into the 2013 PQRS Program.
  • Establishing Interim Final Direct PE RVUs for CY 2012 – Table 21.
  • Medicare Refinement Panel Process.

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.

Comment letters submitted to CMS on the Hospital Outpatient Prospective Payment System (HOPPS) regulations. 

Final Rule for calendar year 2014 (1/27)

  • 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); and
  • 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.

Final Rule for calendar year 2013 (12/12)
Key comments focused on:

  • Proton Beam Therapy (APCs 0664 and 0667).
  • Intraoperative Radiation Treatment (IORT) (APC 0065).

Proposed Rule for calendar year 2013 (9/12)
Key comments focused on:

  • Intraoperative Radiation Treatment (IORT).
  • Proton Beam Therapy.
  • Device Construction for Intensity Modulated Radiation Therapy (IMRT).

Final Rule for calendar year 2012 (1/12)
Key comments focused on:

  • Packaging of new intraoperative radiation therapy (IORT) delivery CPT codes 77424.
  • IORT delivery by X-ray and 77425 IORT delivery by electrons.
  • CY 2012 paymentfor CPT code 77338, Design mlc device for IMRT (APC 0305).
  • Establishment of a review body for the supervision of outpatient services.

Comment letters submitted on Additional Medicare Regulations 

Content last updated 4/11/2014
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