Relevant, Timely Medical and Radiation Oncology News

Constant advancements in 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.

August 2017 Radiation Oncology News

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OMG! Did You Read The CY 2018 OPPS Proposed Rule?

You may be an expert in communicating through text messages, acronyms and emoji's; however, are you an expert in interpretation of the CMS vernacular?  The medical field relies on the understanding of acronyms, abbreviations and even Latin, but oftentimes people forget that CMS communicates with a different language that may be Greek to you and your practice.

Recently, CMS published the CY 2018 OPPS Proposed Rule, which was full of this exclusive language and included terms such as conditional and unconditional packaging.  While review of the proposed fees may indicate a potential reimbursement increase for certain services next year, a closer look may tell a different story.

CMS assigns a Status Indicator (SI) to each HCPCS code defining the status of the code, such as deleted, packaged or separately paid.  One concept communicated through the SI code is the concept of Conditional Packaging, which allows a single code to be paid separately if performed alone or packaged depending on other codes reported.  This type of packaging is defined by SI codes Q1 and Q2.  CMS defines that Q1 indicates a service would be packaged if performed on the same date of service as a code with S, T or V Status Indicator and Q2 applies to packaging with code defined with a SI of T.

Previously, low cost drug administration codes, such as CPT® 96372 Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular were excluded from this type of packaging; however,  in the recent proposed rule, CMS has suggested  conditional packaging would apply to certain Level 1 and 2 drug administration services.  If this proposal is finalized, this would result in this code and other administration codes defined with the Q1 Status Indicator to be packaged when billed with other codes defined as S, T or V, resulting in the loss of separate payment.

While the reimbursement for these codes is not a total loss, understanding when and how these codes will be paid is important to understand the financial impact of this proposed change.  Misinterpretation or misunderstanding of the CMS dialect can adversely affect compliance, reimbursement and the ability to forecast revenue for future years.

If you don't have time to learn a new language, let Revenue Cycle Inc.  be your interpreter for this complex language.  RCI offers of a variety of consulting options, including ongoing support through our Client Resource Center.  For information on our services, please contact us at  or 512-583-2000.

April 2017 Medical Oncology News

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MedPAC Recommends New Part B Drug Pricing System

In early March 2017 the Medicare Payment Advisory Committee (MedPAC) was presented with recommendations by the chairman for reforming the Part B drug payment program. On April 6, 2017, MedPAC voted unanimously to recommend a competitive pricing program and other reimbursement changes for the Medicare Part B drug program.

The new pricing system would include a voluntary Drug Value Program (DVP). The DVP would include a small number of vendors who would negotiate prices paid for the drugs; however, these vendors would not be the ones shipping the drugs. The providers who volunteer in the DVP would purchase the drugs at the vendor-negotiated rate and Medicare would then pay the providers the rate plus an administration fee. The administration fee would be based on either the Medicare Physician Fee Schedule (MPFS) or Hospital Outpatient Prospective Payment System (HOPPS) rate. Additionally, participating providers would also be able to share in any cost savings as part of the DVP.

Additional changes to the Part B drug program by MedPAC include the following: 

  • Improving reporting of the average sales price (ASP) data. All manufacturers of drugs covered under Part B would be required to report data, not just those who have arrangements with Medicaid, and penalties would increase for those not reporting. 
  • Payments modified for drugs paid at wholesale acquisition cost (WAC) to WAC +3%; a reduction from the current rate of WAC +6%. 
  • Limit payment rate increases for drugs based on ASP. Currently there is no limit on how much the payments can increase. Manufacturers would pay a rebate if their products’ ASP exceeded a particular inflation benchmark, such as the consumer price index. 
  • Implement consolidated billing codes for biosimilar drugs. Reference biologics and their biosimilars would be paid under a single code; this would match the current process for brand-name drugs and their generic counterparts. Additionally, the Health and Human Services Secretary might also consider using a consolidated billing code for groups of products with similar health effects.

In an effort to make the DVP more attractive for providers to participate in, the ASP add-on percentage would be cut. If these changes by MedPAC were implemented, the Part B drug program could result in a projected decrease in spending of $250-$750 million in the first year and $1 billion to $5 billion over the next 5 years.  

MedPAC also attended a presentation on what a Medicare premium support program would include in the event Congress and the Trump administration instituted such a program. A Medicare premium support program would provide Medicare beneficiaries with a set amount of money from the federal government to purchase one of several health insurance plans available. Concerns were discussed if such a program was instituted and what it could mean for beneficiaries of various incomes or how access to information by beneficiaries could impact their decisions for healthcare. MedPAC indicated they were not endorsing a premium support program, but felt it was their responsibility to discuss and provide information and advice concerning ideas others have mentioned to revamp the Part B drug program.  

You can stay current with oncology coding and reimbursement news through Revenue Cycle Inc.’s Client Resource Center (CRC) which offers easily accessible answers around the clock, along with a library of resources and articles. To find out about an annual subscription and all of our consulting services, please call us at 512-583-2000 or visit our contact page.