In the Final Rule, CMS (Centers for Medicare and Medicaid Services) did not issue national pricing and continued carrier pricing for the 2022 calendar year on Category I CPT codes 93241, 93243, 93245 and 93247 for extended external electrocardiograph (ECG) monitoring, the relevant codes for the Company’s Zio XT service.
CMS recommended a price of $200.15 (the average of the 10 invoices received by CMS) for such wearable ECG patches, but did not set that as the reimbursement level for 2022 as the agency awaits more stockholder feedback.
The company and other industry participants have been working with Medicare Administrative Contractors (MACs) to establish pricing for the codes. iRhythm said in a news release that it remains engaged with all parties to submit additional cost data on long-term continuous ECG monitoring in an effort to establish fair and appropriate local rates.
iRhythm said it can not provide certainty on the potential outcomes of the discussions with the MACs or on the timing of any action to be taken.
“While we are disappointed that national pricing was not included in the 2022 physician fee schedule, we are appreciative that CMS continues to engage with industry and other stakeholders to further their understanding of the cost components of AI-based solutions such as iRhythm’s Zio service. We firmly believe that national pricing remains the best option for all stakeholders,” iRhythm President and CEO Quentin Blackford said in the release. “In the meantime, we will continue to work with the MACs to provide information for the calendar year 2022 rate-setting process and believe the Final Rule is potentially constructive in our conversations with the MACs. We will share updates at the appropriate time.”
BTIG analyst Marie Thibault wrote in a report that the recommended $200.15 price is significantly higher than current contractor pricing, meaning the Final Rule includes positive signs for iRhythm, as the industry’s efforts and invoice submissions had an impact on CMS’ decision-making.
Thibault and BTIG understand that there is a fairly high likelihood of a national pricing decision for iRhythm’s platform in 2023.
“While a $200 price is not as high as IRTC might have hoped, we believe it should be enough to enable a viable business model for the Medicare segment and, importantly, limit major rate cuts by commercial payers in the future,” Thibault wrote. “However, the near-term reimbursement question remains unanswered, and we expect IRTC will continue to work with its regional Medicare Administrative Contractor, Novitas (Private), to secure a more favorable price level in the meantime.”