Relevant, Timely Medical and Radiation Oncology News

Constant advancements medical technology and healthcare regulations mean the oncology industry is dynamic and fast-changing. To keep clients on the leading edge of what's happening, Revenue Cycle Inc. maintains the news section of its website as a clearinghouse for oncology news, CPT® coding and/or business operations. Whether it's a legal change that could affect our industry or a tip about oncology coding, you'll find it here.

For more information about how our team of expert consultants can help your practice stay current on these industry changes, visit our medical and radiation oncology service page.

October 2015 Radiation Oncology News (View More News and Articles)

Prostate Cancer, the Gel Spacer and How to Code

Teri Bedard BA, R.T. (R)(T), CPC

The treatment of prostate cancer brings with it the challenges of treating the prostate while ensuring the dose to surrounding structures, such as the rectum, are as low as reasonably achievable. Currently, we have different systems in place that help. Providers can use implanted fiducial markers to better visualize the prostate with image guidance taken at the time of treatment. The physician and therapists can then localize the target and deliver treatment as intended, with any dose, to surrounding structures kept within planned limits.

New technology in the form of a gel spacer has recently been approved by the FDA for prostate cancer patients.  The gel is injected between the prostate and rectum to position the patient’s anterior rectal wall as far from the prostate as possible. By creating this space between the prostate and rectum, the radiation dose to the rectum would be reduced, thereby also reducing the severity of late rectal toxicity side effects typically seen in patients when the rectum could not be spared. When injected, the gel solidifies. Over time, it liquefies and is excreted in the urine.

Previously the use of a gel spacer was reported with the unlisted CPT® code 45999 (unlisted procedure, rectum).   Effective October 1, 2015, HCPCS code C9743 (injection/implantation of bulking or spacer material [any type] with or without image guidance [not to be used if a more specific code applies]) will be the code to report in place of the rectal unlisted code. The gel has been and will continue to be reported with A4649 (surgical supply; miscellaneous). 

Table 1 outlines the information regarding this new HCPCS code as listed in Transmittal 3333, Attachment A, with the reimbursement information added by Revenue Cycle Inc.

Table 1 – New Separately Payable Procedure Code Effective October 1, 2015

HCPCS Code Short Descriptor Long Descriptor OPPS Sl OPPS APS Effective date 2015 Medicare National Avg. Payment
C9743 Bulking/spacer material impl Injection/implantation of bulking or spacer material (any type) with or without image guidance (not to be used if a more specific code applies) S 0310 10/01/2015 $1,038.12

OPPS APC 0310, which is where HCPCS code C9743 will reside, includes other marker placement codes such as 55876, placement of devices into the prostate; code 49411, placement of devices into the abdomen; and code 32553, insertion of markers into the thorax. This means that all will be reimbursed the same amount in the hospital setting. The markers or gel substance HCPCS codes are reported in the hospital setting but are not separately reimbursed. The markers (A4648) and gel (A4649) are packaged into the reimbursement of the placement code. HCPCS C code C9743 would not be reported by the physician to CMS for reimbursement since “C” codes are not recognized by MPFS for payment. At this time, it would appear the unlisted code would still be reported by the physician for the work performed as part of this procedure under MPFS.

As you stay abreast of advances in cancer treatment and patient care, make sure you and your staff are also clear on how to properly document and code them. The team at Revenue Cycle Inc. is not only well-versed in the intricacies of cancer treatment, they’re also experts in integrating new technologies into your documentation and coding protocol. For more information on how we can help keep your facility running efficiently, contact us at 512-583-2000 or

September 2015 Medical Oncology News News (View More News and Articles)

Targeted Treatment

Gigi Price, R.N., O.C.N., CHONC

Advances in oncology that we’re seeing today, such as targeted treatment, would have sounded like science fiction 30 years ago.  The age of personalized treatments—for example, drugs that target specific molecular aspects of tumors—is here.

Per the American Society of Clinical Oncology (ASCO) article published in July 2015, “The Society Launches the Targeted Agent and Profiling Utilization Registry,” more than 30 drugs are available that are considered to target specific molecular pathways.  In short, these drugs are the arrow shot at the bullseye of a target—cancer cells. This technology allows for personalized treatment specific to the tumor molecular profile.

The majority of these arrow-like drugs are provided in oral formulations.  Below is a snapshot from that ASCO article, with oral and IV added.

Drug, FDA approved indication and target table

If you’ve ever had the privilege of sitting in on or participating in a tumor board meeting then you know one of the areas discussed in the beginning is tumor pathology.  If you’re looking at a newly diagnosed breast cancer, not only do you review the tumor type, but now it’s common that you’ll see the ER/PR status and HER2 status, as well.  The HER2 status is reviewed and results indicating the tumor is positive are required prior to initialization of Trastuzumab (Herceptin).  This is one example of a targeted treatment utilized to treat breast cancer.

A couple of key issues relate to the use of targeted therapies.  First is the need for evidence-based outcomes when the targeted agents are utilized as a treatment option.  The targeted agent may be utilized as a single agent or may be used in conjunction with chemotherapy or other complex drug regimens.  The need for evidence-based data relating to outcomes is critical to the future use of these types of drugs.  When looking at outcomes, adverse events as well as tumor response will need to be taken into account, as indicated by ASCO.

The second issue relates to the fact some of the agents are new and have recently obtained approval from the FDA, so reimbursement for the drug may be a battle.  You must review the language of each payor contract to verify whether the need for prior authorization is required.  We recommend a policy with a pathway to include prior authorization to ensure all steps are completed prior to scheduling a patient to receive treatment.  The policy should also include coding and billing as well as a designated person who will follow the claim from the time it is submitted to the payor until payment is received. Denials must be reviewed as soon as they are received to allow adequate time to provide required evidence-based documentation to support the drug.

Making sure that you follow specific payor guidelines is an important step in your predetermination policy development, especially for new drugs or off-label drug use.  Through staff education, proper documentation and effective checks and balances, you can achieve your goal of maximizing drug reimbursement.  Revenue Cycle, Inc. can help you develop and implement processes that enable you to reach maximum reimbursement goals.  For more information regarding RCI’s services, please contact our consulting team at 512-583-2000.