Every summer, CMS does extensive rulemaking and policy tweaks, as well as setting new prices, in the hospital outpatient setting and physician fee schedule (independent) setting. After a comment period, the final rules appear around November 1, 60 days before the January 1 calendar year.
Here we go! The rules appear first in "typescript" form (PFS 2414 pp, OPPS 1394pp), later in the Federal Register.
Find the physician fee schedule final rule here. Fed Reg version on November 19.
Find the hospital outpatient final rule here. Fed Reg version on November 16.
Press Releases and Fact Sheets
PFS Press release here, fact sheet here
OPPS Press release here, fact sheet here.
Trade Press
Trade press at Fierce Healthcare here. Becker's here. Press release by Digital Diagnostics on CMS's AI pricing moves, here. Many cancer hospital's don't comply with price transparency law, here. RevCycle on PFS here. Fierce Healthcare on PFS here. ASTRO (Radiation Oncology) "deeply concerned," here. See a discussion November 12 by Shatzkes & Borha of the Sheppard law firm here.
Draft Rules
My notes last summer on the draft PFS rule here. My notes on draft OPPS rule here. (Also from summer, the final inpatient rule here.)
For me, topics of interest in the PFS rule this year including telemedicine liberalization, extensive discussion of AI reimbursement, new rules for AI-focused IDTFs, new principles for remote therapeutic monitoring and remote physiologic monitoring (RTM, RPM), regulations for document review, and rules to eject "abusive billing" providers from the program. Several NCDs were proposed for deletion. There were few surprises in the finalization of any of these initiatives.
In an unusual move, CMS priced the Heartflow cardiac image analysis code, which is very rare for a Category III code. CMS did so by referring to the hospital outpatient charge-based rate and then mimicking it in the RVU valuation (see "Nerd Note.") However, according to a late evening iRhythm press release, CMS did not nationally price the extended cardiac monitoring code that iRhythm uses (here, citing 93241, 93243, 93245 and 93247.) New article on Heartflow here.
CMS discusses the impact of infectious disease on ratesetting at p. 385ff, and pain management at 389ff.
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Nerd Note.
CMS proposed to crosswalk the main Heartflow code to the price of the corresponding hospital patient APC (ambulatory payment category), which is set by calculations based on hospital charges. AMA RUC objected that PFS prices must be set by practice expense data such as the RUC provides, related to Balanced Budget Act 1997 Section 4005 and the corresponding CFR regulation. (I cover this RUC objection in a September blog here, see "AMA RUC strongly opposed...") However, I was aware that PAMA 2014 gave CMS broader authority to set RVUs by data inputs it finds appropriate. In the final rule (typescript p. 106ff) CMS notes its PAMA Section 220 authority to set prices with all sorts of data sources under SSA 1848(c)(2)(N). Score one for CMS. However, CMS actually set the price not by direct reverence to the APC dollar value, but by finding a crosswalk code (in the $900 range) that mimicked the OPPS APC value for the code.
In another quite odd twist, (typescript p. 385) CMS after long debated finalized the stockroom price of a Zio patch at $200.15 (SD339) yet declined to finalize the national RVU price that this missing supply code would have established.
