CPIC Reiterates Strong Concerns with CY 2024 OPPS Final Rule and Seeks Future Policy Dialogue with CMS

The Honorable Chiquita Brooks-LaSure, MPP
Administrator, Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1751-P, Mail Stop C4-26-05
7500 Security Blvd.
Baltimore, MD 21244-1850

Re: CMS-1786-FC - Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Payment Systems; Quality Reporting Programs

Dear Administrator Brooks-LaSure:

We are writing today as stakeholders across the medical imaging and cardiology community to express concern and opposition to the agency’s decision to reassign CPT code 78431 [(Myocardial imaging, positron emission tomography (PET), perfusion study; multiple studies at rest and stress (exercise or pharmacologic)] to APC 1522, as announced in the Centers for Medicare & Medicaid Services (“CMS”) Calendar Year (CY) 2024 Hospital Outpatient Prospective Payment System (“OPPS”) final rule with comment (“Final Rule”) and published in the Federal Register on November 2, 2023. Cardiac PET has been proven to be the most effective modality of non-invasive molecular imaging for diagnosing, treating, and preventing cardiovascular diseases, the leading cause of death in this country. This policy change will inhibit adoption of cardiac PET and present barriers to patient access. We urge you to reverse it.

Despite robust public comments advocating against a reassignment, CMS finalized its proposal to shift CPT code 78431 from APC 1523 to APC 1522 and institute a new payment rate of $2,250.50. This represents greater than an 18% cut and is, in fact, less than the geometric mean cost of $2,300.26 reflected in the CY 2022 claims data. This change comes only a year after the last APC adjustment and as hospitals are adapting to reporting for this new technology that received a new CPT code relatively recently (effective for CY 2020). This payment rate decrease, coupled with the continued uncertainty and instability in the payment for 78431, provides a disincentive to adoption of cardiac PET/CT, particularly in rural or underserved or under-resourced areas.

Additionally, it is our view that CMS should maintain 78431 in its current APC to allow time for CMS to allow for multiple years of hospital cost data reporting and to ensure the adequacy of the data. This will enable CMS to better identify trends and prevent disruption in access to nuclear cardiology services. During that interim time, we would be eager to partner with the agency to work with hospitals on the best practices to bill and report costs for this new procedure. Cardiac PET has many advantages over other modalities, including a higher accuracy rate and exposing patients to lower levels of radiation. Limiting access to this premier technology will deprive some Medicare beneficiaries the option of this assessment and ultimately may result in poorer outcomes for some cardiac patients. Additionally, lesser quality diagnostics that are used when cardiac PET is not available are not only less effective but lead to additional testing, increasing costs to the individual patient and the healthcare system overall.

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We appreciate the opportunity to express concern about CMS’s policy change that will impact our ability to prevent and diagnose cardiac diseases, the leading cause of death in our country. We again urge CMS to reverse its reassignment of CPT 78431 to APC 1522 in order to preserve access to cardiac PET/CT services, and we would welcome additional dialogue on how to ensure complete and accurate hospital cost reporting for this code. Please do not hesitate to reach out to Phil Cranmer at phil.cranmer@cdlnuclear.com with any questions.

Sincerely,

Lon Wilson, CPIC Board of Directors
Kim McDaniel, CPIC Board of Directors
Walter Stenborg, CPIC Board of Directors