Composite APCs set for imaging

As part of its Outpatient Prospective Payment System (OPPS) payment rule for 2009, the Centers for Medicare & Medicaid Services (CMS) has established a multiple imaging composite methodology, which means it will provide a single composite ambulatory payment classification (APC) payment each time a hospital bills more than one procedure from an imaging "family" on a single date of service. The families are:

  • ultrasound;
  • CT and CT angiography (CTA) without contrast;
  • CT and CTA with contrast;
  • magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) without contrast;
  • MRI and MRA with contrast.

This change has some ED experts concerned about a possible loss of revenue. "This makes it likely for highly acute patients to see reduced payment," offers Mike Williams, MPA/HSA, president of The Abaris Group, a Walnut Creek, CA-based health care consulting firm specializing in emergency services. "With EDs struggling financially anyway, this could be a serious concern."

For example, he points out, standard practice today is to rule out cervical fractures with a CT scan, instead of an X-ray, and a limited ultrasound examination called FAST (Focused Assessment with Sonography for Trauma) now is the standard of practice to rule out bleeding, ectopic pregnancy, etc. "Patients with higher acuity often have more than one of these, but now they will only get paid for one even if you do two," Williams says.

Of course, the distinction is that the patient must receive two imagings in the same family — i.e., two ultrasounds, or two CT scans. Still, says Barbara Tomar, MBA, director of federal affairs for the American College of Emergency Physicians (ACEP) in Washington, DC, "our members in teaching hospitals have concerns that Level I trauma centers do so much scanning that if they are bundled, it could exacerbate their financial stress."

Looking to the future, she says ACEP is concerned about the direction CMS seems to be heading in not reimbursing hospitals for certain "preventable" hospital-acquired conditions (HACs). "That's an area where we have our largest concerns," says Tomar, noting the complexity of trying to apply the "this shouldn't have happened" standard to certain conditions and events.

"Who you attribute it to when the patient has seen multiple people, perhaps in an outpatient clinic before going to the ED?" she poses. "A lot of these things are not very well thought through."