Each summer, CMS releases new omnibus packages of pricing policy and other rules, one for physician fee schedule (and other services like labs), and one for the hospital outpatient setting. In recent years, CMS has grappled with how to pay for AI-type services in either setting, and how to pay for molecular testing in the HOPPS setting, which sees increasing complications added to the 14 day rule.
CMS releases both packages of rules on July 13, 2023. The rules appear in typescript "inspection copies" today, and in the Federal Register in ten days. The rules come with CMS summaries in the form of CMS press releases. Both rules require massive spreadsheet attachments.
PHYSICIAN FEE SCHEDULE
Web page here. Inspection copy here (1920 pages). Fed Reg copy on August 7. Comment period 60 days. Fact sheet here.
HOSPITAL OUTPATIENT SCHEDULE
Web page here. Inspection copy here (963 pages). Fed Reg copy on July 31. Comment period 60 days. Fact sheet here.
FLUFFY PRESS RELEASES
In addition to the rules, spreadsheets, and fact sheets, CMS releases a puffy fluffy press release for each rule. The PFS version here. The OPPS version here.
PFS RULE
The PFS rule includes some conforming updates regarding PAMA, such as reporting in 1Q2024, lab prices and payments from 1H2019, to set a new 3-year price schedule in CY2025-26-27 Lab PAMA 431ff/1920.
There are some changes to telemedicine. CMS requests comment on possible updates to CLIA for histopathology (aka AP), cytology, and clinical cytogenetics. (CLIA 834ff/1920)
Although radiology Appropriate Use Criteria software is required by a section of PAMA 2014, CMS is putting that program on ice for now, rescinding 42 CFR 414.94. I've always wondered whether we might suddenly one day see AUC rules in genomics. AUC 726ff/1920.
There's some discussion of digital RVU valuation, p32/1920.
See also 158/1920 in context of FFRCT, th dicussion getting lively around 159/1920 in reference to a new Category I code for FFRCT, 7X005. It will be crosswalked to the TC of 93457, which is an angiography code. FFRCT 159/1920. There's a request for info on digital cognitive behavior therapy (Topic 8, 304-308/1920). This is released to codes for remote therapeutic monitoring (e.g. 989X6). There's a discussion of remote digital cytopathology reading (Dig Cytopath 833/1920).
OPPS RULE
The OPPS rule contains requests for comment on how CMS bundles, or overbundles, diagnostic tracers into pricing for radiology scans (e.g. a PET scan pays the same bundled rate whether the tracer is $300 FDG or $2000 Amyvid). Radiology stakeholders will be commenting vigorously on that. (See ACR summary
here). I thought I saw, somewhere, reference to a bill to unbundle radiotracers from the base scan fee.
See the ACR "Preliminary Summary" of the HOPPS rule
here (4pp). (See ACR's summary of PFS
here.)
In January 2023, AMA created a set of digital pathology codes (0751T ff) and added a couple dozen more in July 2023. I expected the codes, which were too late for discussion in the July 2022 rule, to be discussed in this OPPS rule (they are all classed as nonpayable in the hospital outpatient setting). But, I don't see a word of discussion yet. Maybe CMS feels it is so obvious these codes would be bundled or nonpayable in the OPPS setting, that it feels no need to verbalize why.
In radiology, I notice an MR imaging program for liver with AI, 0648T/49T, is classed as New Tech APC Level 11, paying $950. [SAAS p 165/963]. There's a brief solicitation of info on harms of AI on page 607/963.
