On August 2, 2001, the Centers for Medicare and Medicaid Services, formerly known as HCFA, announced its proposed physician fee schedule for 2002. Generally, the proposed schedule represents minor tweaking of the practice expense portion of radiology fees, but in the area of mammography, the changes are, arguably, the most significant of at least the last decade. The true crux for mammography, however, remains unknown, as the Ambulatory Payment Classification (APC) values for mammography services have not yet been announced for 2002. These will determine whether mammography continues to be delivered in hospital outpatient settings.
By far the most important change was the assumption by CMS of the responsibility for setting the reimbursement rates for screening mammography. For the first time since the early nineties, Congress will not set the payment rate.
From a positive standpoint, the global reimbursement rate for screening, computed using the 2001 conversion factor, will be $88.38 with the technical/professional split being set at $50.89/37.49. This represents an increase of almost 70% in the professional portion of the fee. The increase on the technical side is smaller, at $3.81, but it does bring the technical component of the fee closer to the cost of providing the service in a nonhospital setting.
Full-field digital mammography (FFDM) also benefited from the proposed rule, as CMS continued the increased rate for FFDM that went into effect April 1, 2001, but was due to expire at the end of 2001. Screening
and diagnostic rates increased slightly ($136.68/144.23); however, the big news is that the percentage allocated to the technical component was increased substantially, to 72.5% and 67%, respectively. Unilateral diagnostic FFDM will also be reimbursed ($116.69), with approximately the same technical percentage as for bilateral diagnostic FFDM.
With a $15 global reimbursement due to expire at the end of 2001, the future of CAD was also in question prior to the publication of the proposed rule. CMS not only continued but increased reimbursement by 30% to $19.51 to pay for the addition to the screening mammogram, and established the code as an add-on code to be separately coded whenever the technology is utilized. Here, too, CMS took a second look at the technology and changed the allocation of the fees to $16.07 technical, and $3.44 professional, to reflect the capital expenditure required to access the technology.
With a global fee of $107.89 for screen-film screening mammography and CAD, divided $66.95/$40.94 for the technical component and professional fee, the rate is considered to be at a point where, given attention to a cost-effective delivery system, screening mammography no longer needs to be considered as the stepchild of radiology. In fact, high-volume, productive breast centers can generate sufficient revenue to justify investment in important new technologies for which there may not be universal reimbursement, but that may provide enhanced patient care.
A Curious Oversight?
The rosy reimbursement forecast presented above, however, applies only to centers that do not fall under the Hospital Outpatient Prospective Payment System.? CMS has just released its proposed rule outlining the new APC payment rates for 2002. The current APC reimbursement rate (analog for the technical component) for diagnostic mammograms, $35.17, is a long way from the $90-plus per mammogram recently calculated in an ACR survey as the technical cost of providing a mammogram in a hospital setting. Yet the CMS proposal reduces the proposed payment by almost 7.5%, to $32.54, and applied the rate to digital diagnostic mammography as well as screen film. CMS did not, however, provide an APC code for either screening mammography (analog or digital) or for CAD utilized with screening mammography. This omission, while it may just be a mistake, creates a large planning issue for all hospital-based mammography programs. The old, Congressionally mandated reimbursement rate will no longer be effective on January 1, 2002. What will replace this rate, and how can hospitals plan to serve their mammography patients?
[A CMS spokesperson has indicated that the reimbursement rate for hospital-based screening mammograms will be based on the revised physician fee schedule rate. Nowhere in the proposed rule, however, is this documented.]
It is obvious that hospitals will not be able to afford to continue to provide the much higher volume screening mammograms if the diagnostic APC value is applied to screening mammography.? At a cost of more than $90 per mammogram, and a reimbursement rate of $32.54, a hospital-based breast program with a volume of 20,000 mammograms would lose more than $1 million per year on mammography alone. There are no statistics that indicate what percentage of screening mammograms are delivered in a hospital outpatient setting; however, the relative percentage must be substantial. Consider the impact on patient access to mammography if hospitals were to withdraw their support of this service. The hard-won benefits of screening mammography that US women are beginning to accrue would begin to erode over a few short years.
CMS has taken a significant first step toward righting the inequities of mammography reimbursement: It needs to complete this action with realistic APC reimbursement for all mammography services.
Gerald R. Kolb, JD, is CEO of Breast Health Management Inc, Bend, Ore, [email protected].