CMS sets national fee schedules for most drugs, DME, and physician services. However, there are numerous codes that are "Status C" or "Contractor Priced."
In my experience, for years, these locally prices often weren't published anywhere. Now, they frequently are published. Here are two examples.
- When the new Category I codes for the service provided by iRhythm were released in January 2021, they didn't have RVU values, meaning, they didn't have national prices.
- However, Wall Street analysts quickly tracked what their local prices were, because MACs (in this case Novitas) released them. And then you'll find investor calls where iRhythm management talk about how they're working with Novitas, how Novitas might revise the locally-set payment, and so on. (Entry point to the trade press, here.)
- Beginning this year, the MolDx program places its locally-set prices on a special website called "DEX" Diagnostics Exchange, here. Story here. (This followed some policy debates whether locally-set fee schedules product prices for Medicare providers were available under FOIA or were a business secret of a MAC).
Noridian as an Example
If you go to the Noridian MAC website, they've got a dedicated page for fee schedules, hre:
And they've got a special page for "contractor status" codes:
It looks like they provide one annual excel spreadsheet - by County in California - and PDF updates monthly or quarterly. They include a range of Category III codes (which are almost never priced by CMS) and those Category I or numeric-series codes which aren't priced by CMS.
In the current CMS Part B code schedule, I see about 8000 priced codes (CMS status A) and 1000 unpriced codes (Status C), although that's an overcount because some of the C-codes are in pairs (technical, professional components).
HeartFlow & Local Prices
Heartflow has CPT codes 0501T (comprehensive service), 0502T (data preparation), 0503T analysis with sophisticated mathematical model, 0504T (physician interpretation.) In the hospital outpatient OPPS system, CMS does not assign OPPS prices (called APCs) for 0501T and 0504T because they contain, in part or in whole, a physician Part B service. However, CMS assigned pricing to 0502T and 0503T in the OPPS system. 0503T, for 2022, is proposed in OPPS APC as APC 1511 and price $950. 0502T was reviewed for OPPS APC pricing but assigned status N. (Final for CY2022 expected around November 1; proposed policies online here and at 86 FR 42018-42360 (August 4, 2021).
- When the Heartflow code was new to the APC system, CMS initially priced it higher, $1500, based on some invoice data available at that time, prior to CMS access to hospital outpatient claims data.
CMS nearly never assigns prices in Part B RVU units to Category III codes, and that's true for the national prices of the series (or lack of prices) for 501T-504T. However, if you look at the Noridian files above, 0504T is assigned a price of $17 - physician's interpretation of Heartflow service. At least so far, Noridian has not published any Part B prices for the other Heartflow codes 0501T-0503T.
But the CMS PFS CY2022 rule does propose to deal with Heartflow codes in RVU's despite their Category III status. See website here and at 86 FR 39104-39907 (July 23, 2021). Therein, CMS proposed to create 2022 prices for Heartflow codes based on 2022 OPPS prices. The comments website is here; 35,000 comments received.
Regarding the use of APC pricing to set Part B RVUs, AMA RUC strongly opposed use of the Heartflow APC price in the Part B realm (with conversion to RVUs). RUC cites to the Balanced Budget Act of 1997, requiring some simple rules for setting RVUs (must use generally accepted accounting principles for staff, equipment, supplies, etc). "Use of the relatively of hospital charge data to determine the relativity of practice costs is not consistent with statutory provisions...". But RUC does not mention, that a later law, PAMA Section 220 in 2014, gave CMS wide new authorities for where it could source data for setting RVUs. Here, here.
In its comment, Heartflow did not object to APC pricing but used several facts to argue for a higher APC/PFS price ($1100 not $950). Here. Heartflow appears to have also submitted a data analysis by the consultancy Braid-Forbes on the nuances of this pricing.
