Proposed HOPPS rule would increase breast biopsy reimbursements

The proposed rule for changes to the hospital outpatient prospective payment system (HOPPS) for 2015, recently released by the Centers for Medicare & Medicaid Services, would significantly increase breast biopsy payments.

This represents a fix to last year's HOPPS rule, which resulted in payment reductions for stereotactic, ultrasound, and MRI-guided vacuum-assisted breast biopsy. In the 2014 rule, two CPT codes--those representing breast biopsy with core needle and breast biopsy with vacuum-assisted or rotating device--were replaced by six new codes (CPT codes 19081-19086) that bundled payments for breast biopsy procedures and assigned them ambulatory payment classification codes (APC). That move resulted in reduced payment rates.

Now, CMS is proposing to fix the APC placements of the bundled breast biopsy codes by placing all the needle biopsy procedures into two existing APCs. The reassignment of codes 19081, 19083, and 19085 would result in a payment rate of $1,062, which is 51 percent higher than the 2014 payments rate of approximately $702.

Women's imaging advocates had warned against the cuts contained in the HOPPS 2014 rule, with some arguing that the reimbursement cuts could result in a decline in the availability of breast interventions since some hospitals, such as those found in the inner city and rural areas, won't be able to afford to provide them.

For example, in an article in the Journal of the American College of Radiology in January, Ezequiel Silva, III, M.D., of the University of Texas Health Center, pointed out that with those cuts ultrasound-guided biopsy would be reimbursed to around $700, which would basically just about cover cost of the vacuum-assisted biopsy device.

Scientists working on the MARIUS (magnetic resonance imaging using ultrasound--systems and processor multimodal MR imaging) Project, an undertaking of the Fraunhofer Institute for Biomedical Engineering IBMT in St. Ingbert and the Fraunhofer Institute for Medical Image Computing MEVIS in Bremen, are developing a more cost-effective breast cancer biopsy technique that is supposed to be easier on patients.

The proposed rule, if unchanged, goes into effect Jan 1, 2015, and has a 60-day comment period ending Aug. 30.

To learn more:
- see the proposed rule (.pdf)