Advocacy Alert: High-volume PET/CT Code Rate Increases in CY2023 HOPPS Proposed Rule

The Centers for Medicare & Medicaid Services (CMS) has released the Hospital Outpatient Prospective Payment System (HOPPS) proposed rule for CY2023.
ASNC's advocacy team will perform a thorough analysis of CMS's proposals. For now, we want to draw your attention to where the proposed rule places PET/CT codes in CMS's Ambulatory Payment Classification (APC) categories. 

A preliminary analysis of the proposed rule shows the PET/CT codes would remain in the New Technology APCs.

As an example, consider PET/CT code 78431 (Myocardial imaging, positron emission tomography, perfusion study [including ventricular wall motion[s], and/or ejection fraction[s], when performed]; multiple studies at rest and stress [exercise or pharmacologic], with concurrently acquired computed tomography transmission scan) is proposed to move from New Technology APC 1522 where the payment rate is $2,250.50 in CY2022 to New Technology APC 1523 with a higher payment rate of $2,750.50 in CY2023.
CMS is proposing the following for the assignment of the PET/CT codes:

  • Place code 78431 (Myocrd img pet rst&strs ct) in APC 1523 (New Technology - Level 23) with a payment rate of $2,750.50.

  • Place code 78432 (Myocrd img pet 2rtracer) in APC 1520 (New Technology - Level 20) with a payment rate of $1,850.50. (Note, however, that this placement is according to the text of the proposed rule. ASNC has noted a discrepancy between the rate in the proposed rule text vs. CMS's data files, where the proposal is $1,750.50 in APC 1519. ASNC will address this discrepancy with CMS and will update you.) 

  • Place code 78433 (Myocrd img pet 2rtracer ct) in APC 1521 (New Technology - Level 21) with a payment rate of $1,950.50.

ASNC will report on additional HOPPS policy details, including the proposed payment rates for cardiac PET and SPECT. Stay tuned to ASNC for updates. 

Not Clear on APCs or Why They Matter? Watch a Little 'Health Policy 101' Now 

ASNC's Health Policy 101 video series features ASNC Past President Randall C. Thompson, MD, MASNC, explaining key concepts clinicians should understand about health policy and advocacy. Episode 2, Ambulatory Payment Classifications & Your Reimbursement, focuses on an issue many clinicians mistakenly believe they can leave to their administrative staff.
Why does it matter which APC category your services are housed in? How could a reclassification impact the payments you receive for your services? Dr. Thompson answers these and more questions in this engaging video.