Proposed rule would reorganize APCs, update quality reporting measures

CMS kicked off the month of July with a new proposed rule for changes to the 2016 hospital outpatient prospective payment system (HOPPS). The rule included several proposed updates that could have a large impact on radiologists moving forward.

The rule proposes to change HOPPS rates by -.1%. CMS reached this number by starting with a projected hospital market basket increase of 2.7%, but then subtracting a total of 2.8% based on legal requirements and various projections.


HOPPS is the payment system for approximately 3,800 hospitals and 60 community mental health centers, and its payments are determined by the Ambulatory Payment Classification (APC) assigned to the service or procedure in question. A major component of CMS’ proposed rule is that it will “restructure, reorganize, and consolidate” a large number of APCs in nine different categories. Nine new Comprehensive APCs (C-APCs), which include payment for a primary procedure and all secondary services related to that primary procedure, are also being proposed. There are presently 25 C-APCs in place.

CMS wishes to rely more on these all-encompassing payments going forward, so a Healthcare Common Procedure Coding System (HCPCS) modifier is also being proposed. The modifier would help CMS collect and analyze data related to a C-APC’s primary procedure and any services related to that procedure, even services reported on a different claim altogether.

In additional APC-related news, CMS is proposing that low dose CT scans for lung cancer screening be included in APC 5570, Computer Tomography without Contrast. In a statement about the proposed rule, the ACR said it will be watching the APC placement of these codes “carefully.”

Quality Reporting

CMS also proposes adding two new measures to the Hospital Outpatient Quality Reporting (HOQR) Program in the next few years: External Beam Radiotherapy (EBRT) for Bone Metastases, starting in 2018, and Emergency Department Transfer Communication, starting in 2019. The former involves the percentage of patients who receive EBRT for painful bone metastases and no history of previous radiation, and the latter involves the percentage of patients transferred to another facility “whose medical record documentation indicated that administrative and clinical information was communicated to the receiving facility in an appropriate time frame.” Both measures have been approved by the National Quality Forum.

The rule also proposes the removal of one reporting measure, Use of Brain CT in the Emergency Department for Atraumatic Headache. This measure is no longer up to date with current clinical guidelines, CMS said.

In addition, some minor tweaks have been proposed to the HOQR program in an attempt to align its schedule with the Ambulatory Surgical Center Quality Reporting Program (ASCQR).

Tracking Smart Dose Compliance

Beginning in 2016, Medicare will pay 5% less for scans performed on CT systems found to not comply with the new XR-29-2013 standard, also known as Smart Dose CT. In 2017, that penalty jumps to 15%. Another part of this new proposed rule from CMS is a modifier that would make it easier to track claims that involve CT scans performed with devices that do not comply.

Comments about the rule will be accepted until Aug. 31, 2015. A final rule is expected on or around Nov. 1, 2015. More info from CMS about this proposed rule can be found on its website.