Monday, August 26, 2019

CMS Proposes Big Heartflow Price Cut for Outpatients; MAC Proposes Detailed Coverage Rules

A couple years ago, I outlined the remarkable and serpentine saga as the Heartflow fractional flow reserve (FFR) test moved from Medicare non coverage to coverage.   (For example, at one point, Heartflow's MAC wouldn't even let it enroll in Medicare as a provider.) 

My main blog on the Heartflow topic was in April 2018, and ended with Heartflow categorized into an outpatient payment category of $1500.  Here.   (An even nerdier version of the story is here.)

Heartflow uses very sophisticated software on site to provide dynamic analyses of cardiac CT imaging taken elsewhere, leading to better and less invasive management of patients.  The company has raised several hundred million dollars over the years.  Funding includes $65M in June 2019 and $240M in February 2018 (here).

Saga Continues Summer 2019

The story continues in Summer 2019.

  • First, Palmetto GBA MAC provides a proposed LCD for coverage of Heartflow FFR, including detailed patient criteria, exclusion criteria, and technician and physician training criteria.  CMS copy here, cloud copy here
  • Second, CMS proposes to halve the outpatient Heartflow price.  CMS originally placed the Heartflow code in a New Tech Payment Category for $1500. That was for CY2018.   Now, in summer 2019, CMS says it has enough data from 840, CY2018 hospital claims to reclassify Heartflow's code in a far lower payment category.  Original APC was APC 1516 ($1450) and proposed new APC is APC 1509 ($750).  See 84 Fed Reg 39459-60 (August 9, 2019).   Here.    
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Medicare Nerd Trivia

One way that Medicare can pay for diagnostic tests is as "purchased tests," where e.g. the treating cardiologist "purchases" the technical component of a report and finalizes it (signs-it-out).  The physician can bill this "purchased test" to Medicare (by law, with no mark-up), but he has to report the entity that did the test, its location, its NPI.  CMS confirms if the test originator was validly enrolled.  See R3255CP, October 2015, Part B claim for purchased test to be handled as "unprocessable...if the [original supplier] cannot be verified as a valid, Medicare-enrolled entity" (at 10.1.1.2).  Here.   

Heartflow might not be a Medicare-enrolled entity.  You can look up the NPI here, which seems to be 1982019980.  If you go to Opedge/PECOS, it comes back with a "red" rather than "green" check (see pic below) which may mean that this NPI isn't enrolled in Medicare.   See: https://opedge.com/Pecos.   As noted above, CMS did process 840 Heartflow code claims at hospitals, suggesting that hospitals don't have to validate if a supplier is Medicare-enrolled or not.