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.

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

OPDIVO (nivolumab)

By Gigi Price, RN, OCN, CHONC

Throughout the year, the FDA receives new data submitted by pharmaceutical manufacturers and research entities.  After an intensive review of this information, the FDA grants labeling changes to existing approved drugs, adds new indications for use, initiates an accelerated approval, proceeds with regular approval or decides more information is required from related research entities before it can grant approval for use in humans.  

Here is a synopsis of the new drug OPDIVO, which is being used in hematology and oncology settings as of December 22, 2014—more than three months ahead of the goal date of March 30, 2015. 

The FDA considered OPDIVO under its priority review program, which provides an expedited review for drugs that have the potential of being a significant improvement in the safety or effectiveness in the treatment of a serious condition.     

OPDIVO was granted FDA approval for use in the treatment of unresectable or metastatic melanoma.  A criterion for receiving the drug includes disease progression following treatment with ipilimumab.  Other factors such as BRAF V600 mutation and BRAF inhibition are also examined before consideration of treatment with OPDIVO. 

OPDIVO is marketed by Bristol-Myers Squibb and available in 40mg/4ml (NDC 0003-3772-11) and 100mg/10ml (NDC 0003-3774-12) single-dose vials. The recommended dose is 3mg/kg administered as an intravenous infusion over 60 minutes. 

The HCPCS code for OPDIVO usage depends on the setting and payor guidelines; generally, J9999 (not otherwise classified antineoplastic drug) is used in the non-facility setting and C9399 (unclassified drugs or biologicals) is used in the hospital outpatient setting.  Billing is linked to the vial NDC size per 1 unit. 

If the infusion is the primary reason for the encounter, facilities and non-facilities should report V58.12 as the primary diagnosis.  A diagnosis code from the following list would then be reported as the secondary diagnosis. 

Diagnosis Codes

ICD-9                         

172    Malignant melanoma of the skin

172.0 Malignant melanoma of skin of lip

172.1 Malignant melanoma of skin of eyelid including canthus

172.2 Malignant melanoma of skin of ear and external auditory canal

172.3 Malignant melanoma of skin of other and unspecified parts of face

172.4 Malignant melanoma of skin of scalp and neck

172.5 Malignant melanoma of skin of trunk except scrotum

172.6 Malignant melanoma of skin of upper limb including shoulder

172.7 Malignant melanoma of skin of lower limb including hip

172.8 Malignant melanoma of other specified sites of skin

172.9 Malignant melanoma of skin, site unspecified

Managing the administrative aspects of FDA approvals is imperative and ensuring specific payor guidelines are applied is an important step of your documentation and billing compliance plan.  Revenue Cycle Inc. can help with refining and implementing processes to achieve your compliance goals. Staff education, proper documentation and effective checks and balances are just a few of our specialties. For more information regarding Revenue Cycle Inc.’s services, please contact our consulting team at 512-583-2000.

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

SGR Patch Likely for April; Permanent Fix could be 4-6 Months Down the Road

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

At the end of the day on March 31, 2015 the current SGR (Sustainable Growth Rate) patch will expire. Unless Congress takes action, the current Medicare Physician Fee Schedule (MPFS) conversion factor (CF) of $35.7547 will be adjusted to decrease approximately 20 percent. At a recent AMA conference, Representative Tom Price (R-GA), who is an MD and chairs the House Budget Committee, said, "I believe ... in March we'll come up with a patch, likely for 4 to 6 months, and then come forward with full-scale repeal." Many believe the permanent fix of the SGR would be tied to the reauthorization of the Children's Health Insurance Program (CHIP), which expires at the end of September. 

Former Mississippi Governor Haley Barbour also indicated that members of Congress are working for a repeal of the SGR by September 30. Health and Human Services (HHS) Secretary Sylvia Burwell, who also appeared at the conference, stated that the president’s fiscal year 2016 budget proposal calls for a fix and that she hopes it can be changed in full.

Secretary Burwell addressed comments received by CMS on meaningful use. Concerns voiced by providers indicated that many thought the objectives and timing of meeting the criteria were “too much, too fast.” In response, CMS has recently announced plans to make “meaningful use more straightforward, flexible and focused on outcomes and interoperability.”

Another concern is the transition to ICD-10 scheduled for October 1, 2015. Rep. Price urged AMA attendees to visit with senators and representatives on Capitol Hill and request a delay in implementation, or permission to use a hybrid system that would allow a practicing physician to choose between using ICD-9 or ICD-10. 

In a separate meeting, members of the House of Representatives’ Energy & Commerce Subcommittee on Health expressed support of the ICD-10 implementation date of October 1, 2015 and have urged fellow lawmakers to not delay any further. Members of the subcommittee cited the significant amounts of time and money invested by CMS and providers to prepare for this 2015 implementation date and asserted that any delay could be financially burdensome. CMS and many providers would incur additional costs to keep ICD-9 systems current, retrain employees and once again prepare for the transition. 

Representatives of 3M and other healthcare companies testified with lawmakers to keep the October 1, 2015 deadline for the ICD-10 transition. A representative from the American Urological Association suggested, however, that the implementation was too costly for some providers to bear and voiced support of the delay. A recent study by the American Academy of Professional Coders (AAPC) concluded that ICD-10 implementation costs in small physician practices (defined by AAPC as less than 10 providers) were approximately $750 per provider. 

In addition, CMS recently announced successful end-to-end testing of ICD-10 reporting from January 26-February 3. Reporting was performed by health care providers, clearinghouses and billing agencies. Approximately 660 providers and nearly 15,000 test claims were submitted for the test week. Overall findings supported that claims were able to be successfully submitted with ICD-10 coding. For those claims that were rejected, most had errors unrelated to the diagnosis coding (ICD-9 or ICD-10).

Two more testing weeks are scheduled: April 27-May 1 (volunteers have been selected) and July 20-July 24 (volunteer forms will be available March 13 on the MAC and CEDI websites). Those who volunteered and participated in the January testing will be automatically eligible to volunteer in the upcoming sessions.

We all need to stay tuned because the next few weeks should be interesting! One thing on which we can agree: our industry is ever-changing. Staying abreast of Congressional action, CMS changes and proposed rules, AMA perspectives and news from other healthcare organizations can be overwhelming. Call on the consultants at Revenue Cycle Inc. to keep you informed. Understanding the needs of your practice, we’ll distill these constant developments and navigate you through our changing climate so that your staff and operations stay efficient, compliant and profitable. Contact us at 512-583-2000 or info@revenuecycleinc.com for more information.