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.

February 2016 Radiation Oncology News (View More News and Articles)

National Coverage Determinations (NCDs) - What Are They and How Do They Help?

Adam Brown, BSRT(T), CMD

A National Coverage Determination (NCD) is a determination of whether Medicare will pay for an item or service. According to the Centers for Medicare and Medicaid Services (CMS), “Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation.”  

NCDs can be requested by parties who identify an item or service as a potential benefit to Medicare beneficiaries. The following may request an NCD:

  • Medicare beneficiaries
  • Manufacturers
  • Providers
  • Suppliers
  • Medical professional associations
  • Health plans

NCDs can also be internally generated by CMS for the following:

“For existing items or services:

  • Stakeholders have raised significant questions about health benefits of currently covered items or services
  • New evidence, or re-interpretation of previously available evidence indicates that current policies may need to be changed
  • Local coverage policies are inconsistent or conflicting, to the detriment of beneficiaries

For new items or services:

  • The technology represents a substantial clinical advance and is likely to result in significant health benefit if it is available more rapidly to patients for whom it is indicated
  • More rapid access is likely to have a significant programmatic impact on Medicare policies
  • Significant uncertainty exists around health benefits, patient selection, or appropriate facility and staffing requirements”

The development of an NCD process generally takes six to nine months, depending on the need for external technology assessments or coverage advisory committee reviews. For those that do not require this additional work, the entire NCD decision will be made no more than six months after the date of the request.  

During the first six months the following processes take place:

  • Preliminary Discussions
  • Benefit Category
  • National Coverage Request
  • Staff Review
  • External Technology Assessment and/or Medicare Coverage Advisory Committee
  • Staff Review
  • Draft Decision and Memorandum Posted

The last three months are broken out into only two steps: 

  • Public Comments (30 days)
  • Final Decision Memorandum and Implementation Instructions, which must be completed in the remaining 60 days  

So how do NCDs and LCDs (Local Coverage Determinations) work together? NCD decisions are binding for all Medicare Administrative Contractors (MACs), and LCD policy cannot be more restrictive than the NCD; however, it may be less restrictive. For example, if an NCD states an item is covered for a certain diagnosis, contractors should not develop a policy to cover only that specific diagnosis. When an NCD does not exclude coverage for other diagnoses, contractors should allow consideration unless the LCD supports automatic denial of some or all of those diagnoses. It should be noted that CMS is required under the Medicare Modernization Act (MMA) to evaluate and decide which decisions should be adopted nationally.  

Here is a brief list of current NCDs that can serve as a resource when educating your staff on the latest rules and regulations regarding oncology services:

 National Coverage Determinations (NCDs)
 Abarelix for the Treatment of Prostate Cancer (110.9)
 Anti-Cancer Chemotherapy for Colorectal Cancer (110.17)
 Aprepitant for Chemotherapy-Induced Emesis (110.18)
 Autologous Cellular Immunotherapy Treatment (110.22)
 Blood Brain Barrier Osmotic Disruption for Treatment of Brain Tumors (110.20)
 Colorectal Cancer Screening Tests (210.3)
 Hyperthermia for Treatment of Cancer (110.1)
 For Infusion Pumps (280.14)
 Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (210.14)
 Prostate Screening Tests (210.1)
 Scalp Hypothermia During Chemotherapy to Prevent Hair Loss (110.6) 
 Smoking and Tobacco-Use Cessation Counseling (210.4)

Make sure your practice and facility stay in front of the latest updates and code changes. Take advantage of Revenue Cycle Inc.'s Client Resource Center, which provides ongoing consulting services when you need them. For more information on an annual subscription and how our experts can help keep you informed and operating smoothly, please contact us at 512-583-2000 or revenuecyleinc.com.

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

CY2016 Final Rule for Radiation Oncology Released

Radiation Oncology Final Rule Summary

The CY2016 Final Rules for Radiation Oncology contained many potential changes to the Medicare Physician Fee Schedule including the proposed conversion factor, practice expense and malpractice updates, misvalued codes, radiation treatment and related image guidance services and more. Hospital Outpatient Prospective Payment System highlights are comprised of changes to the payment rates, APC names/codes, C-APC for SRS procedures and the new HCPS codes released in August. The Revenue Cycle Inc. team has thoroughly reviewed and condensed the changes for the radiation oncology industry into two documents. Within these summations are examples of potential reimbursement based on the interpretation of the published ruling. To read the summaries, click on the links below to download a PDF.

CY2016 Final Rule for Radiation Oncology – MPFS

CY2016 Final Rule for Radiation Oncology – HOPPS

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

CY2016 Final Rule for Medical Oncology Released

Medical Oncology Final Rule Summary

According to the recent release of the CY2016 Final Rules for Medical Oncology, highlights of changes to the Medicare Physician Fee Schedule include adjustments to the conversion factor, misvalued codes and payment for biosimilar biological products. The Hospital Outpatient Prospective Payment System focal points consist of, but are not limited to, changes in the OPPS payment rates for both rural and community hospitals, packaging policies, the conversion factor, payment changes for drugs, biologicals and radiopharmaceuticals and more. The Revenue Cycle Inc. team has comprised a summary of the changes for the medical oncology industry into two documents. To read the summaries, click on the links below to download a PDF.

CY2016 Final Rule for Medical Oncology – MPFS

CY2016 Final Rule for Medical Oncology – HOPPS

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.