HOPPS 2027 Proposed Rule: CMS Proposing Reorganization of Nuclear Medicine APCs

On Thursday, July 2, the Centers for Medicare & Medicaid Services (CMS) released the 2027 Hospital Outpatient Prospective Payment System (HOPPS) proposed rule, which includes consequential proposals for nuclear cardiology and for imaging services broadly. ASNC is currently analyzing the rule and will share additional details in the weeks ahead. ASNC’s Health Policy team will also respond to CMS with formal comments.

Hospital Outpatient Payment Update

CMS is proposing a 2.4% facility payment increase for hospital outpatient departments that meet quality reporting requirements.

Reorganization of the Nuclear Medicine and Related Services Ambulatory Payment Classification

CMS proposes to reorganize the code assignments in the nuclear medicine ambulatory payment classifications (APCs) while maintaining the 4-level APC structure for nuclear cardiology services. CMS cites its 2025 policy of paying separately for radiopharmaceuticals and the observed impact of the policy on the remaining services in the nuclear medicine APCs as the reason for the proposed reorganization.

High-Volume PET/CT Code Would Move Out of New Technology APC
CMS proposes moving the 78431-78433 codes series from the New Technology APC to the Nuclear Medicine APC 5594. CMS states there are sufficient claims for the following CPT codes to be moved out of the New Technology APCs and into clinical APC groupings:

• 78431 – Myocardial imaging, positron emission tomography (pet), 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
• 78432 – Myocardial imaging, positron emission tomography (pet), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability)
• 78433 – Myocardial imaging, positron emission tomography (pet), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), dual radiotracer (eg, myocardial viability); with concurrently acquired computed tomography transmission scan

Stay tuned to ASNC for the exact 2027 proposed payment rates. ASNC plans to meet with CMS regarding this issue after completing an impact analysis.

Payment for Diagnostic Radiopharmaceuticals

CMS proposes updating the per-day cost threshold that triggers separate payment for diagnostic radiopharmaceuticals from the current $655 to $665.

For radiopharmaceuticals that are paid separately, CMS proposes to continue setting reimbursement using the arithmetic mean unit cost as a proxy for the average price for a diagnostic radiopharmaceutical. CMS is encouraging manufacturers to submit average sales price (ASP) information for radiopharmaceuticals, with the possibility that ASP data could be used in the future for setting payment rates.

Site-Neutral Payment Policy for Non-contrast Imaging

Citing an increase in the volume of imaging services paid for by the hospital outpatient department and an increase in utilization per beneficiary despite the declining Part B fee-for-service beneficiary population, CMS is proposing to use its authorities to extend its site-neutral payment policies to non-contrast imaging services when furnished at an excepted, off-campus provider-based department.

Under the proposed policy, CMS would apply the Medicare Physician Fee Schedule equivalent payment rate to Healthcare Common Procedure Coding System codes assigned to the imaging-without-contrast APCs and to services paid through the following APCs:

5521 — Level 1 Imaging Without Contrast
5522 — Level 2 Imaging Without Contrast
5523 — Level 3 Imaging Without Contrast
5524 — Level 4 Imaging Without Contrast
8004 — Ultrasound Composite
8005 — CT and CTA Without Contrast Composite
8007 — MRI and MRA Without Contrast Composite

This proposed change would have a significant impact on the vast majority of imaging services, although it is not expected to impact nuclear cardiology tests.

More Analysis Coming Soon

For more information on the 2027 Hospital Outpatient Prospective Payment System proposed rule, refer to these CMS resources:

• 2027 Hospital Outpatient Prospective Payment System Proposed Rule
• 2027 Hospital Outpatient Prospective Payment System Proposed Rule Fact Sheet

In the coming days, ASNC will complete its analysis and share details as well as an update on its advocacy plan with ASNC members.

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