On July 3, 2008 the Centers for Medicare & Medicaid Services (CMS) posted a proposed notice for Medicare payment for hospital outpatient services and ambulatory surgical centers (ASC) for calendar year (CY) 2009.  The proposed rule affects hospital outpatient and ASC payments for services paid under the hospital outpatient prospective payment system (HOPPS) and ASC system.  The rule includes a 3.0 percent annual inflation update to Medicare payment rates for most services that would be paid under the OPPS. 

Important proposed policies related to nuclear cardiology include:

• CMS is proposing to set the payment rates for nuclear cardiology procedures based on the 2008 final rule established rate setting methodology using claims that include a charge for a required diagnostic radiopharmaceutical or other radioactive product.
  
• CMS continues to bundle add-on “image processing services” with the costs of the major procedure CPT codes.  (Examples of bundled CPTs are 78478, 78480 and 78496.)
  
• CMS proposes increased packaging for multiple imaging services (an extension of “composites”) provided in one session; targeted modalities are Computed Tomography (CT) and Cardiac CT Angiography, Magnetic Resonance Imaging (MRI and MRA) and ultrasound services.  CMS states that it is proposing this policy to encourage greater efficiency by changing how it pays for imaging services when multiple services are provided in one session.  Under the proposal, CMS would make a single payment for multiple services of the identified modalities through five newly created imaging composite APC groups.  This new policy is intended to encourage imaging efficiencies, similar to the multiple procedure reduction currently implemented in the Physician Fee Schedule. 
  
• CMS continues bundling payments for all diagnostic radiopharmaceuticals (RPs) and contrast agents in with the APC category (major service procedure).  CMS again states that it considers these items to be ancillary/supplies.  For (new) transitional pass-through diagnostic RP payments, CMS proposes to use the device methodology to estimate RP offset costs that could reasonably be attributed to the diagnostic RP packaged into APC groups in an effort to avoid duplicate payments. 
  
• CMS proposes to pay separately for drugs, biological and therapeutic radiopharmaceuticals costing $60 or more per day.  Payments for other drugs will continue to be bundled into payments for their associated procedures.
  
• Separately payable therapeutic radiopharmaceuticals are proposed to be paid by CMS utilizing voluntary manufacturer-submitted average sales price (ASP) information through the existing ASP process at ASP +4 percent as the best proxy for therapeutic RP average acquisition and handling costs.  If ASP information is not available, CMS is proposing that payment would be based upon mean costs from hospital claims data.
  
• Drugs and biological are proposed to be paid at 104 percent of the average sales price (ASP +4), rather than the current rate of 106 percent of ASP paid in the office and IDTF setting.
  
• CMS is also proposing changes to the hospital Medicare cost report to improve the accuracy of future cost estimates used to determine payment for drugs and biological. 

The 2009 HOPPS proposed rule is now posted on the CMS Web site at: http://www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/CMS-1404-P.pdf.

The information from this proposed notice would be effective for services on or after January 1, 2009.