2021 HOPPS Final Rule Summary - ASTRO

2021 Hospital Outpatient Prospective Payment System ? Final Rule Summary

On Wednesday, December 2, 2020, the Centers for Medicare & Medicaid Services (CMS) released the 2021 Hospital Outpatient Prospective Payment System (HOPPS) final rule, which includes modest payment increases for radiation therapy services effective January 1, 2021. Comments on the final rule are due January 1, 2021.

In the Medicare hospital outpatient environment, hospital reimbursement is based on Ambulatory Payment Classifications or APCs. CMS assigns CPT codes to an APC based on clinical and resource use similarity. All services in an APC are reimbursed at the same rate. Cost data collected from OPPS claims are used to calculate rates. Certain services are considered ancillary and their costs are packaged into the primary service. Packaged services do not receive separate payment. For example, in the hospital outpatient environment imaging is not paid separately when reported with treatment delivery services. Below is a summary of key issues impacting radiation oncology.

Annual Update

CMS is finalizing increased payment rates under the OPPS by an Outpatient Department (OPD) fee schedule increase factor of 2.4 percent. This increase is based on the hospital inpatient market basket percentage increase of 2.4 percent for inpatient services paid under the hospital inpatient prospective payment system (IPPS). Based on this update, CMS estimates that total payments to HOPPS providers (including beneficiary cost-sharing and estimated changes in enrollment, utilization, and case-mix), for 2021 will be approximately $84 billion, an increase of $7.5 billion compared to 2020 HOPPS payments.

Ambulatory Payment Classifications (APC)

CMS is finalizing modest changes to the payment rates of traditional radiation oncology APCs in the 2021 HOPPS final rule. Below is a list of radiation oncology APCs with their final 2021 payment rates:

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Radiation Oncology - Ambulatory Payment Classification 2021 Payment Rates

APC

5611

5612

5613 5621 5622 5623

5624 5625 5626

Descriptor Level 1 Therapeutic Radiation Treatment Preparation Level 2 Therapeutic Radiation Treatment Preparation Level 3 Therapeutic Radiation Treatment Preparation

Level 1 Radiation Therapy

Level 2 Radiation Therapy

Level 3 Radiation Therapy Level 4 Radiation Therapy - HDR Brachytherapy

Level 5 Radiation Therapy - Proton Therapy

Level 6 Radiation Therapy - SBRT

2020 Rate $127

$335

$1,245 $123 $236 $539 $740 $1,247 $1,768

2021 Rate $127

$339

$1,262 $121 $242 $543 $708 $1,298 $1,734

% Change

0%

1%

1% -2% 3% 1% -4% 4% -2%

Comprehensive Ambulatory Payment Classifications (C-APCs)

CMS continues to expand the Comprehensive Ambulatory Payment Classification (C-APC) methodology by finalizing two new C-APCs. These new C-APCs include the following: C-APC 5378 Level 8 Urology and Related Services and C-APC 5465 Level 5 Neurostimulator and Related Procedures. The addition of these C-APCs increases the total number of C-APCs to 69. Under the C-APC policy, CMS provides a single payment for all services on the claim regardless of the span of the date(s) of service. Conceptually, the C-APC is designed so there is a single primary service on the claim, identified by the status indicator (SI) of "J1". All adjunctive services provided to support the delivery of the primary service are included on the claim. While ASTRO supports policies that promote efficiency and the provision of high-quality care, we have long expressed concern that the C-APC methodology lacks the appropriate charge capture mechanisms to accurately reflect the services associated with the C-APC.

In the 2021 HOPPS final rule, CMS does not make any modifications to existing radiation oncology C-APCs. Below is a comparison table of the 2020 payment rates and finalized 2021 payment rates for the radiation oncology services in several key C-APCs:

CPT Code

77371 77372 77424 77425

C-APC 5627 Level 7 Radiation Therapy

Descriptor

2020 Rate

SRS Multisource SRS Linear Based IORT delivery by x-ray IORT delivery by electrons

$7,942 $7,942 $7,942 $7,942

2021 Rate

$7,733 $7,733 $7,733 $7,733

% Change

-2% -2% -2% -2%

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C-APC 5092 Level 2 Breast/Lymphatic Survery and Related Procedures

19298 Place breast rad tube/caths

$5,237

$5,534

6%

C-APC 5093 Level 3 Breast/Lymphatic Survery and Related Procedures

19296 Place po breast cath for rad

$8,135

$8,920

10%

C-APC 5113 Level 3 Musculoskeletal Procedures

20555 Place ndl musc/tis for rt

$2,737

$2,830

3%

C-APC 5165 Level 5 ENT Procedures

41019 Place needles h&n for rt

$4,850

$5,086

5%

C-APC 5302 Level 2 Upper GI Procedures

43241 Egd tube/cath insertion

$1,557

$1,625

4%

C-APC 5375 Level 5 Urology and Related Services

55875 Transperi needle place pros

$4,231

$4,414

4%

C-APC 5415 Level 5 Gynecologic Procedures

55920 Place needles pelvic for rt

$4,271

$4,410

3%

57155 Insert uteri tandem/ovoids

$4,271

$4,410

3%

58346 Insert heyman uteri capsule

$4,271

$4,410

3%

In the 2020 HOPPS final rule, CMS reassigned CPT codes 57155 Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy and 58346 Insertion of Heyman capsules for clinical brachytherapy from C-APC 5414 Level 4 Gynecologic Procedures to C-APC 5415 Level 5 Gynecologic Procedures. For 2021, these codes continue to see modest increases in reimbursement (5 percent). However, ASTRO remains concerned that these services are still undervalued. Despite efforts to encourage the Agency to value these services more appropriately, CMS remains committed to the methodology and does not intend to modify it for radiation oncology services. ASTRO is disappointed by this and will continue to educate CMS on the impact the C-APC methodology has on radiation oncology services, particularly brachytherapy.

Medical Physics Dose Evaluation (CPT code 76145)

CMS finalized placing newly created CPT code 76145 in APC 5611 Level 1 - Therapeutic Radiation Treatment Preparation. APC 5611 currently has nine, clinically similar radiation oncology therapeutic radiation treatment codes. ASTRO previously provided comments to CMS asserting that CPT code 76145 is not a radiation oncology code, rather a service that will be performed in interventional radiology or interventional cardiology and the service is better suited in APC 5724 - Level 4 Diagnostic Tests and Related Services with a payment rate of $936.70. APC 5724 has 17 services, with a range of clinical variability (urology, neurology, internal medicine, radiology, dermatology, allergy, etc) and the resource consumption in APC 5724 more closely aligns with the resources used to perform CPT code 76145. Despite our concerns, CMS is moving forward with the placement in the C-APC 5611, asserting that the APC category is the most appropriate assignment for the code because there is no claims data

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available for OPPS rate-setting. The Agency will review the APC assignment at a later time once claims data is available to determine whether a change is necessary.

Addition of New Service Categories for Hospital Outpatient Department (OPD) Prior Authorization Process

In the 2020 HOPPS final rule, CMS established prior authorization requirements as a condition of Medicare payment for five categories of services: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation. Section 1833(t)(2)(F) of the Act directs the Secretary to establish a method to control "unnecessary increases in the volume of services" under the OPPS. CMS determined that some services experienced significant increases in volume. CMS selected these procedures specifically because they have both therapeutic and cosmetic indications, and utilization of these services has increased rapidly in recent years.

In the 2021 HOPPS final rule, CMS is including two new categories of services for prior authorization, cervical fusion with disc removal and implanted spinal neurostimulators. CMS asserts that prior authorization is an effective mechanism to ensure Medicare beneficiaries receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in volume by virtue of improper payments, without adding onerous new documentation requirements. The Agency states that the addition of these service categories is consistent with their vested authority under section 1833(t)(2)(F) and is based an unnecessary increase in the volume of these services. Services contained in these two categories are subject to prior authorization for dates of service on or after July 1, 2021.

ASTRO submitted comments expressing concern about CMS' decision to expand the use of prior authorization as a method for addressing the issue. Despite our concerns, the Agency continues to be committed to expanding prior authorization policies. ASTRO continues to believe that the use of prior authorization results in delays in care and erodes the value of physician-patient decision making process. Burdensome prior authorization policies have become a blunt instrument used by private payers and Medicare Advantage plans to prevent patients from accessing care.

Two-Times Rule Exception

CMS finalized the continuation of the two-times rule exception for APC 5612 Level 2 Therapeutic Radiation Treatment Preparation and a new two-times rule exception for APC 5627 Level 7 Radiation Therapy. CMS established two-times rule criteria within the APC methodology that requires that the highest calculated cost of an individual procedure categorized to any given APC cannot exceed two times the calculated cost of the lowest-costing procedure categorized to that same APC. However, the Agency can exempt any APC from the two-times rule for any of the following reasons:

Resource homogeneity; Clinical homogeneity; Hospital outpatient setting utilization;

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Frequency of service (volume); and Opportunity for upcoding and code fragments

Brachytherapy Sources

In the 2021 HOPPS final rule, CMS is finalizing to base the payment rates for brachytherapy sources on the geometric mean costs for each source, except where otherwise indicated, which is consistent with the methodology used for other services under HOPPS. Additionally, the Agency will use the costs derived from 2019 claims data to set the 2021 payment rates for brachytherapy sources.

CMS is making an exception to this methodology for C2645 Brachytherapy planar source, palladium-103, per square millimeter because it only had one claim in 2019 with over 4,000 units at a rate of $1.07 per mm2, which CMS does not believe is adequate, so the Agency will continue to use 2018 claims data that established the rate of $4.69 per mm2 in 2021 for C2645.

CMS is finalizing payment for HCPCS codes C2698 Brachytherapy source, stranded, not otherwise specified and C2699 Brachytherapy source, non-stranded, not otherwise specified, at a rate equal to the lowest stranded or non-stranded prospective payment rate for such sources, respectively on a per source basis. For 2021, the finalized rates are $38.38 for C2698 and $32.32 for C2699. This is a 6 percent increase in payment for C2698 from the 2020 rate of $35.96 and a 11 percent decrease for C2699 from the 2020 rate of $36.45. CMS continues to invite recommendations for new codes to describe new brachytherapy sources for consideration in future rulemaking.

2021 HOPPS Final Rule - RO Model Modifications

The 2021 HOPPS final rule includes significant changes to the Radiation Oncology Alternative Payment Model (RO Model), including confirmation of CMS' October 22nd announcement delaying the implementation date from January 1, 2021 to July 1, 2021 based on hardships practices have experienced during the COVID-19 public health emergency. Secured by ASTRO's advocacy, the delay necessitates other changes to the model, including shortening the model term, delaying the start of quality measure data reporting, clinical data element collection and reporting, and the use of Certified Electronic Health Record Technology (CEHRT). Those changes mean there will be no quality withhold in performance year (PY) 1; therefore, the model will not qualify as Advanced APM in the first performance year, which removes the 5% bonus on professional component services. However, the discount factors and anticipated negative trend factor would still apply in year 1.

Below is a summary of the key changes to the RO Model.

RO Model Duration

As it was introduced in the Specialty Care Models to Improve Quality of Care and Reduce Expenditures (Specialty Care Models) final rule, the RO Model was anticipated to start on

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