Removal of Restrictive Criteria for Low Osmolar Contrast Media (LOCM)
in the Physician Office and Clinical Settings
The Centers for Medicare and Medicaid Services (CMS) advised in the November
15, 2004 Medicare Part B Physician Fee Schedule Final Rule that they
were eliminating the restrictive criteria for use of LOCM in the physician
office and freestanding clinical settings. CMS, however, failed to publish
a transmittal instructing carriers to acknowledge the change. Consequently,
many carriers ignored the final rule and continued to restrict payment
for LOCM. On July 29, 2005, CMS released claims transmittal 627 to resolve
the inconsistent payment practice for LOCM.
For more information, visit:
http://www.cms.hhs.gov/manuals/
pm_trans/R627CP.pdf Healthcare Common Procedural Coding System (HCPCS) Codes for Radiopharmaceuticals
Used with Positron Emission Tomography (PET)
On July 29, 2005, CMS also released claims transmittal 628. This
transmittal updates chapter 13, section 60, of the CMS claims
processing manual.
The update includes the addition of the HCPCS codes for radiopharmaceutical
agents that should be billed with PET services performed on or after
January 28, 2005.
For more information, visit:
http://www.cms.hhs.gov/manuals/
pm_trans/R628CP.pdf
Competitive Acquisition Program (CAP) Interim Final Rule
The Medicare Prescription Drug, Improvement, and Modernization Act
(MMA) of 2003 revised the “incident to” physician services provision
(section 1861 (s) (2) (A)) of the Social Security Act. This revision
permits payment of “incident to” drugs under the CAP. Radiopharmaceuticals
and contrast agents are excluded from the CAP at this time. CMS published
the CAP interim final rule in the July 6, 2005 federal register.
For more information, visit: http://a257.g.akamaitech.net/7/257/2422/
01jan20051800/edocket.access.gpo.gov/2005/pdf/
05-12938.pdf
Average Sales Price (ASP) Third Quarter Payment File
CMS released the third quarter ASP file on June 20, 2005. Updated
payment rates for contrast agents are listed on this file.
For more information, visit: http://www.cms.hhs.gov/providers/drugs/asp.asp 2006 Proposed Rule for the Hospital Outpatient Prospective Payment System
CMS published the 2006 proposed HOPPS rule in the Monday July 25,
2005 Federal Register. The proposed rule brings a significant
number of
changes for radiopharmaceuticals, contrast agents, and imaging procedures.
CMS proposes to reduce payment by 50% for certain multiple diagnostic
imaging procedures within a “family” of procedures within
the ultrasound, CT, CTA, MRI, and MRA modalities. This change is consistent
with a proposal in the MedPAC report to Congress on the growth in spending
on medical imaging procedures.
CMS is proposing to reimburse contrast agents based on ASP in
the hospital outpatient setting. Radiopharmaceuticals that are
separately payable
in CY 2006 would be reimbursed per a temporary one-year policy based
on a hospital’s charge for each radiopharmaceutical adjusted
to cost.
For more information, visit: http://www.cms.hhs.gov/providerupdate/regs/
cms1501P.pdf
Category III Current Procedural Terminology (CPT) Codes for Cardiac
Computed Tomography Angiography (CCTA)
The American Medical Association (AMA) introduced category III
codes for CCTA on July 1, 2005. The codes are scheduled for
implementation
in January of 2006. Category III codes are temporary codes listed in
the CPT manual as emerging technology, services, and procedures. Category
III codes are intended to be used for data collection purposes to substantiate
widespread usage. These codes are usually not referred to the Relative
Value Scale Update Committee (RUC) for valuation. Payment for these
services/procedures is based on the policies of payers not
on a yearly fee schedule based
on relative value units.
For more information, visit:
http://www.ama-assn.org/ama/pub/category/
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