Industry News, November 2024

​A bipartisan group of House lawmakers recently introduced a bill that would reverse the impending 2.83 percent Medicare Physician Fee Schedule (MPFS) payment cut, which the Centers for Medicare and Medicaid Services (CMS) proposed  in July, and subsequently  finalized  in November in the 2025 MPFS final rule.

House Introduces Bill to Reverse Impending MPFS Payment Cut

The intent of  “The Medicare Patient Access and Practice Stabilization Act of 2024” (H.R. 10073) is to amend title XVIII of the Social Security Act to increase support for physicians and protect access to care for Medicare beneficiaries by adjusting Medicare payment changes. Specifically, this bill would not only reverse the pending cuts, but also give physicians a raise of 1.8 percent. This raise would offset nearly one half of the projected Medicare Economic Index (MEI) increase for 2025 of 3.5 percent, which measures annual changes (inflation) of physician operating costs.

The urgency to get this bill passed before January 1, 2025, is compounded by the fact Congress is facing a lame-duck session. Unless Congress works to pass this bill during this year’s session, the payment cuts will go into effect.
​
Among the many organizations advocating for this bill is the American Medical Association (AMA). In a recent statement, AMA President Bruce A. Scott, M.D. said, “The end-of-year panic over pending Medicare cuts faced by physicians year after year is getting old for patients, physicians and members of Congress. There needs to be a systematic reform that makes Medicare payment rational, predictable and sustainable. Unfortunately, for the last many years the only predictable thing has been that physicians must brace themselves for another round of cuts…Although it might sound oxymoronic, we need an active lame duck. The 66 million patients who rely on Medicare are counting on that.” 

---

SNMMI Celebrating CMS’ Update of PET Radiopharmaceutical Payment Policy

As reported in the July 2024 Industry News, the Centers for Medicare and Medicaid (CMS) proposed a new reimbursement policy for diagnostic positron emission tomography (PET) scans that would provide separate payment for radiopharmaceuticals that have a per-day cost of more the $630, as well as extra payment for hospitals when they use domestically produced technetium-99m. The Society of Nuclear Medicine and Molecular Imaging (SNMMI) supported this proposed change to the current packaging policy for diagnostic radiopharmaceuticals.

CMS finalized this new reimbursement policy in the 2025 HOPPS final rule, and it will now replace the existing policy in which diagnostic radiopharmaceuticals are considered supplies and packaged into the imaging procedure. It should be noted any diagnostic radiopharmaceutical with a per-day cost of less than $630 will continue to be packaged under the current policy. 

Of interest is Pylarify® (piflufolastat F 18), an imaging agent that is primarily utilized in PET scans for men with prostate cancer. Pylarify® was approved by the Food and Drug Administration (FDA) in 2021 as a radioactive diagnostic agent indicated for use with a positron emission tomography (PET) scan of prostate-specific membrane antigen (PSMA) positive lesions in men with prostate cancer with suspected metastasis who are candidates for initial definitive therapy, or with suspected recurrence based on elevated serum prostate-specific (PSA) level. This PET radiopharmaceutical will be separately reimbursed under the finalized payment policy, effective January 1, 2025.
​
In a statement issued by the SNMMI, the society recognized the limitations of the current policy and were celebrating this policy update as it marked “the culmination of SNMMI’s persistent efforts over the past 16 years.” The society also stated it would continue to work closely with CMS to “refine and enhance the reimbursement models to ensure sustained and equitable access to advanced diagnostic care for all patients.”

---

New for 2025: MRI-Monitored Transurethral Ultrasound Ablation (TULSA) Codes

A​mong the new CPT® codes for 2025 are the transurethral ultrasound ablation (TULSA) procedure codes. These codes were established to report a minimally invasive, radiation-free, ultrasound-utilized and MRI-monitored treatment of prostate cancer or benign prostatic hyperplasia (BPH). This procedure uses thermal ultrasound to perform the ablation and MRI guidance during the procedure: 

• 51751 – Insertion of transurethral ablation transducer for delivery of thermal ultrasound for prostate tissue ablation, including suprapubic tube placement during the same session and placement of an endorectal cooling device, when performed
• 55881 – Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation
• 55882 – Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation; with insertion of transurethral ultrasound transducer for delivery of thermal ultrasound, including suprapubic tube placement and placement of an endorectal cooling device, when performed

This procedure differs from code 55880, which is performed with high intensity-focused ultrasound (HIFU) via transrectal approach.
​
Coding guidelines state these codes should not be reported with one another and should not be reported with the pelvis MRI codes (72195-72197) or the MRI-guidance code for tissue ablation (77022). 

---

ACR Releases New and Updated Appropriateness Criteria

The American College of Radiology® (ACR®) released new and revised topics for its ACR Appropriateness Criteria® (ACR AC). The update includes 8 new and 18 revised topics, each including a narrative, evidence table and a literature search summary:

New Topics:

1. Assessment of Cardiac Function and Baseline Cardiac Risk Stratification in Oncology Patients  
2. Brain Tumors  
3. Evaluation of Coronary Artery Anomalies  
4. Imaging for Pulmonary Embolism, Known Clot  
5. Imaging of Ductal Carcinoma in Situ (DCIS)  
6. Inflammatory Ear Disease  
7. Lung Cancer: Surveillance After Therapy  
8. Staging and Follow-up of Anal Cancer  

 
Revised Topics:

1. Acute Hip Pain   
2. Acute Respiratory Illness in Immunocompetent Patients   
3. Acute Shoulder Pain   
4. Acute Spinal Trauma   
5. Back Pain-Child   
6. Cervical Pain or Cervical Radiculopathy   
7. Chronic Dyspnea-Noncardiovascular Origin  
8. Chylothorax Treatment Planning   
9. Colorectal Cancer Screening   
10. Dementia   
11. Fever Without Source or Unknown Origin-Child   
12. Management of Iliac Artery Occlusive Disease   
13. Ovarian Cancer Screening   
14. Renal Transplant Dysfunction   
15. Supplemental Breast Cancer Screening Based on Breast Density   
16. Suspected and Known Heart Failure   
17. Suspected Primary Bone Tumors   
18. Thoracic Aortic Aneurysm or Dissection-Treatment Planning and Follow-Up   ​

Launched in 1993, the ACR AC are evidence-based guidelines to help providers make appropriate imaging and/or treatment decisions for specific conditions, developed and reviewed annually. According to the ACR, “Employing these guidelines helps providers enhance quality of care and contribute to the most efficacious use of radiology. The AC are not intended to be used as coding guidance for radiologic procedures.” Currently, the ACR AC includes 247 diagnostic imaging and interventional radiology topics with more than 1,2000 clinical variants and 4,000 clinical scenarios. 
​
The ACR AC website has an interactive AC portal that can be used to access the AC topics, variants, clinical scenarios and recommendations. The site also allows for feedback and comments on any topic. Users can comment on existing content and suggest new content. Additionally, the Journal of the American College of Radiology (JACR), together with the ACR AC Patient Engagement Subcommittee published patient summaries intended to improve patient comprehension of appropriate tests for their encounter. These summaries are written by patients, for patients, in a language that is easy for the layperson to understand.

---

Lung Cancer Screening Awareness Remains Alarmingly Low

Despite being one of the most effective tools in reducing cancer mortality, lung cancer screening remains underutilized, according to a recent study published in JAMA Network Open. One of the authors, Dr. Gerard Silvestri, senior author and professor at the Medical University of South Carolina (MUSC), emphasized that lung cancer screening is as impactful, if not more, than breast or colorectal cancer screening in saving lives. More than 80% of participants across all demographics—regardless of sex, race, income, or education—had neither heard of nor discussed lung cancer screening.

The study analyzed data from 1,279 individuals who were 50 to 80 years old and either current or former smokers. Key findings include:

• Awareness Gaps: 18.1 percent of former smokers and 13.5 percent of current smokers had never heard of lung cancer screening.
• Lack of Communication: Over 75 percent of former smokers and 71 percent of current smokers had not discussed screening with their clinicians in the past year.
• Missed Opportunities: Even among individuals with a history of cancer or lung disease, more than 60 percent did not discuss screening with a healthcare provider.

Researchers recommend increased educational initiatives in clinics and communities to raise awareness. Encouraging primary care providers to prioritize conversations about lung cancer screening is vital, especially for current smokers, who are at higher risk. Streamlining decision-making tools in clinical practice could also improve screening rates.

Coding for Lung Cancer Screening
Lung cancer screening typically involves low-dose computed tomography (LDCT) and is associated with specific ICD-10 codes:

• Z87.891 - Personal history of tobacco use/personal history of nicotine dependence.
• F17.210 - Nicotine dependence, cigarettes, uncomplicated (current smoker).
• F17.211 - Nicotine dependence, cigarettes, in remission (former smoker).
• Z12.2 - Encounter for screening for malignant neoplasm of respiratory organs.
• Z72.0 - Tobacco use (not dependence).

 
CPT® codes describe the specific services provided during lung cancer screening. Relevant codes include:

• 71271 - Computed tomography (CT), thorax, low-dose for lung cancer screening, without contrast material(s). This code is specifically designated for low-dose CT scans used for lung cancer screening.
• G0296 - Counseling visit to discuss the need for lung cancer screening using low-dose CT (LDCT) scan. Medicare requires this counseling session before the first screening.

---

Significant Increase to CMS Reimbursement for CCTA

A new calendar year (CY) 2025 payment policy for coronary computed tomography angiography (CCTA) exams more than doubles Medicare reimbursement to hospitals that provide these services. In the Hospital Outpatient Prospective Payment System (HOPPS) CY 2025 Final Rule, the Centers for Medicare and Medicaid Services (CMS) finalized reclassifying CCTA exams represented by CPT® codes 75572, 75573 and 75574 into a higher ambulatory payment classification (APC). The higher APC 5572 classification (Level 2 Imaging with Contrast) for these exams results in an increased hospital reimbursement rate of $357.13. This is a significant increase from the CY 2024 reimbursement rate of $175.

A more appropriate compensation for CCTA exams will contribute to improved patient access to these diagnostic tools, which in turn will result in better patient outcomes. The Society of Cardiovascular Computed Tomography (SCCT) has advocated for more appropriate compensation for CCTA services for 6 years. The chair of the SCCT Health Policy and Practice Committee, Dr. Ahmad Slim, stated, “This small coding adjustment creates large ripples for impact, alleviating financial pressure on struggling medical practices and potentially expanding cardiac CT testing at more sites across the country, ensuring better patient access to this cost-efficient exam.”
​
The SCCT November 1, 2024 press release advises hospitals to report cardiology revenue code 0480 for CCTA services, encourages billing departments to ensure that all systems are updated with the new APC 5572 and revenue code, and further encourages hospitals to verify compliance with their local Medicare Administrative Contractor (MAC).

---

Prior Authorization Review Timeframe Changes for the OPD

Effective January 1, 2025, the Centers for Medicare and Medicaid Services (CMS) will  reduce  the timeframe for Medicare Administrative Contractors (MACs) to review Fee-for-Service (FFS) standard prior authorization  requests from 10-business days to 7-business days for certain hospital outpatient department (OPD) services.
 
The goal of this change in policy is to align the timeframes across the prior authorization programs and shorten the wait time for beneficiaries to have access to care.
​
Currently, CMS requires prior authorization for specific hospital OPD services including blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, vein ablation, implanted spinal neurostimulators,  cervical fusion with disc removal and facet joint interventions.

---

Updated HCPCS Codes for Discarded Drugs and Biologicals

​The Centers for Medicare and Medicaid Services (CMS) posted an updated list of HCPCS codes used only for single-dose containers paid separately under Medicare Part B which may require the JW and JZ modifiers, depending on the setting in which the drug is used and reported. This list is updated semi-annually; excludes codes assigned to one or more multiple-dose containers; and does not include all drugs subject to the JW and JZ modifier policy. Codes with one or more multiple-dose containers assigned to it are excluded from the list.