CMS Reverses Medicare Proposal to Cut Hospital Based DXA Payment

ISCD Continues Fight to Restore Payment for Office DXA

Good news for hospital-based DXA providers. Yesterday, the Centers for Medicare and Medicaid Services released the 2017 Hospital Outpatient Prospective Payment System (HOPPS) and restored funding for DXA performed in the hospital setting, following a groundswell of activity by the ISCD and members of the Fracture Prevention Coalition. This major policy reversal is very encouraging and helps the ISCD to set the stage for our continued advocacy efforts to restore funding for DXA provided in the office setting.

In late September, we reported on our meetings with officials from CMS to discuss the proposed cuts to DXA in the HOPPS system. Under the proposed rule, reimbursement would have been cut for Axial DXA, CPT 77080 in the hospital setting from the current national average of $100.69 to $63.33. This cut would have further limited access to DXA testing resulting from the 70% cut to office-based DXA.

The ISCD spearheaded the effort to reverse the payment cut, by developing draft comments for various groups to submit to Medicare, and helping to facilitate the submission of a joint letter, signed by 46 professional organizations and patient groups, urging CMS to evaluate and acknowledge the effect of their office based cuts before making the same mistake with hospital-based DXA.

In addition, over 20 Members of Congress signed a letter urging CMS to reverse the policy. As a result of the combined effort, payment for hospital-based DXA was actually increased from the current $100.69 to $112.69 for each CPT code (77080 and 77085), as opposed to the nearly 40% payment cut proposed in the draft rule. See the excerpt below from the final rule regarding the decision to increase payment for hospital-based DXA.

While this is a step in the right direction, the larger battle over office based DXA cuts is still ongoing. This is the first time that Medicare has reversed a DXA cut; the ISCD will build on this success as we continue our legislative efforts to restore payment to office based DXA. There will be an opportunity to address the office based DXA cuts when Congress returns after the election, and again in March when Congress will have to pass Medicare-related legislation.

Our thanks to all of you who sent emails and made phone calls to help reverse this Medicare payment cut. Your continued support is critical to our success.

Comment: Several commenters objected to the proposed assignment of CPT code 77080 (Dual-energy X-ray absorptiometry (DXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine)) to APC 5521. The proposed assignment would reduce the payment rate for this procedure from its current CY 2016 payment rate of $100.69 to $63.33 in CY 2017. The commenters believed that the payment reduction could impair access to this valuable preventive service. The commenters requested that CMS assign CPT code 77080 to a higher paying imaging APC, along with other services that have greater resource similarity to the procedure described by CPT code 77080.

Response: We agree with the commenters. Therefore, we are modifying our proposal, and assigning CPT code 77080 to APC 5522 (Level 2 Diagnostic Radiology without Contrast) for CY 2017. CPT code 77080 has a geometric mean cost of $91.08, which increases the probability of a 2 times rule violation when compared to the second-lowest-cost significant procedure assigned to APC 5521, the procedure described by CPT code 71010, which has a geometric mean cost of $46.11. We note that we are not comparing the geometric mean cost of CPT code 77080 to that of CPT code 75571, which is a significant procedure assigned to APC 5521 and that has a geometric mean cost of $22.87, for a 2 times rule violation because as described above, this procedure code assignment was the basis for the exception from the 2 times rule for APC 5521 in the proposed rule. In summary, we are assigning CPT code 77080 to APC 5522, with a final payment rate of $112.69 for CY 2017.

Last modified: November 3, 2016