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 Medical Oncology News (View More News and Articles)

New and Revised Place of Services (POS) Codes for Outpatient Hospitals Released by CMS

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

The growing trend of hospitals acquiring physicians and physician practices has raised concern about effectively and accurately establishing payment rates for facility-based pricing by CMS. The total payment for services received by a patient in a hospital-based system is typically higher than payment received in an office-based or freestanding center. The ability to accurately establish and set pricing information for both individual items and indirect Practice Expenses (PE) is critical in establishing accurate PE Relative Value Units (RVUs) for Physician Fee Schedule (PFS) services.

In the HOPPS and MPFS Final Rule for CY 2015 released on October 31, 2014, CMS finalized the need for claims to reflect some kind of identifier to differentiate the services performed in a provider-based department vs. those in an outpatient hospital department. At the time of the Final Rule release a POS or modifier dedicated to provider-based departments was not identified, but was indicated to follow at some later date. On August 6, 2015, CMS released MM9231 New and Revised Place of Service Codes (POS) for Outpatient Hospitals, which states the new and revised POS codes to be implemented January 4, 2016.

New and Revised POS Codes Effective January 1, 2016

Code Descriptor
POS 19 Off Campus Outpatient Hospital Descriptor: a portion of an off-campus hospital provider-based department which provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
POS 22 On Campus Outpatient Hospital Descriptor: a portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

Additional Information Related to POS Codes 19 and 22 was also included in the MedLearn Matters transmittal by CMS.

Payments for services provided to outpatients who are later admitted as inpatients within three days (or, in the case of non-IPPS hospitals, one day) are bundled when the patient is seen in a wholly owned or wholly operated physician practice. The three-day payment window applies to diagnostic and nondiagnostic services that are clinically related to the reason for the patient’s inpatient admission, regardless of whether the inpatient and outpatient diagnoses are the same. The three-day payment rule will also apply to services billed with POS code 19.

Claims for covered services rendered in an Off Campus-Outpatient Hospital setting (or in an On Campus-Outpatient Hospital setting, if payable by Medicare) will be paid at the facility rate. The payment policies that currently apply to POS 22 will continue to apply to this POS and will now also apply to POS 19 unless otherwise stated.

Reporting outpatient hospital POS code 19 or 22 is a minimum requirement to trigger the facility payment amount under the PFS when services are provided to a registered outpatient. Therefore, you should use POS code 19 or POS code 22 when you furnish services to a hospital outpatient regardless of where the face-to-face encounter occurs.

Your MACs will allow POS 19 to be billed for G0447 (face-to-face behavioral counseling for obesity, 15 minutes) and G0473 (face-to-face behavioral counseling for obesity, group [2-10], 30 minutes) in the same way as those services are billed with POS code 22.

Updates on payment policies and coding practices are ever-emerging and keeping abreast of them is vital to optimum documentation, billing and compliance. Our expert consultants at Revenue Cycle Inc. can keep you informed about the latest CMS news, conduct staff training and set up efficient processes that will help your facility maintain a healthy bottom line and meet compliance goals. For more information regarding RCI’s services, please contact our consulting team at 512-583-2000.

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.