Intracoronary imaging and invasive coronary physiology, both critical to improving the quality of patient care in interventional cardiology, are expected to receive a boost from the Centers for Medicare and Medicaid Services (CMS) next year. Historically, CMS policy under the Ambulatory Surgical Center (ASC) payment system has not allowed additional payment for certain “add-on” services. Many of these services are, however, known to enhance quality and reduce unnecessary PCI procedures with the associated diagnostic cardiac procedure. These services include, for example, Fractional Flow Reserve Studies (FFR/iFR reported using CPT^® codes 93571, 93572) and Intravascular Ultrasound or Optical Coherence Tomography (IVUS and OCT reported using CPT^® codes 92978, 92979).  

This ASC policy has been in sharp contrast to the Outpatient Prospective Payment System (OPPS) outpatient hospital payment for these same “add-on” services. When these services are packaged with the diagnostic cardiac procedure, in the outpatient hospital setting, they have triggered a “complexity adjustment” to account for the hospital’s added cost of performing them. This results in a higher payment rate.  

This inconsistency in payment policy between the ASC and OPPS outpatient hospital payment systems has disincentivized physicians from performing these services in an ASC, even though the use of these technologies has been shown to improve lesion selection for PCI, prevent unnecessary procedures, improve patient outcomes, and decrease overall cost to the healthcare system. The SCAI Government Relations Committee has been advocating with industry to get CMS to change this policy for over three years. 

Fortunately, in the CY2023 proposed OPPS rule, CMS is finally proposing to implement a new ASC payment policy that would apply to code combinations that include “add-on” services. CMS proposes to pay for those code combinations at a higher payment rate to reflect that the code combination is a more complex and costlier version of the procedure performed, similar to the way in which the OPPS outpatient hospital complexity adjustment is applied. CMS has now included FFR/iFR/IVUS/OCT in these code combinations. SCAI will comment on the proposal and urge CMS to move forward with this very important policy change.