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.

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

The BID Dilemma

Tamara Syverson, BSRT(T)

With the implementation of new CPT® codes in the hospital outpatient department, you’ve likely come across a denial or two that has left you scratching your head.  The new IMRT treatment delivery codes 77385 and 77386 are good examples.  While the published guidelines and descriptors allow for ease of coding, the issue is related to Medically Unlikely Edits (MUEs), which are set at one (1). 

The MUE program was implemented by Medicare as a means to reduce paid claims error rates by defining a quantity-based edit that delineates how many units of a certain code are acceptable for a single beneficiary on a single date of service.  As well, MUE edits are designated as claim line or date of service edits in reference to the process for adjudication.  For CPT® codes 77385 and 77386, the MUE is designated as a date of service edit; therefore, the previous process of reporting the second treatment code on a separate claim line with a 59 or 76 modifier will likely still result in a MUE-based denial.

 If you have encountered a denial of this type, not all hope is lost—the MUE is assigned a MUE Adjudication Indicator (MAI) of three (3), indicating the edit is based on clinical benchmarks.  Medicare instructs that if denials based on these edits are appealed, Medicare contractors may pay units in excess of the published MUE value. However, supporting documentation of medical necessity and support of the billed quantity would be required. 

As BID fractionation is commonplace for certain diagnoses, such as areas of the head and neck, which typically require IMRT-based treatment techniques. You will likely come across a case like this.  In these scenarios, it would not be recommended to “scrub” the units in excess of MUE to submit a clean claim; rather, report the correct quantity based on the work performed, documented and supported by medical necessity within the medical record. 

Quarterly updates of MUE values help keep you abreast of changes and allow you to identify potential areas for payment delays and denials. We know they are a lot to keep track of, so our team at Revenue Cycle Inc. offers a variety of consulting options that make it easy to stay informed about ongoing changes in oncology coding.  To find out more about what Revenue Cycle Inc. can do for you, please contact our consulting team at 512-583-2000 or info@revenuecycleinc.com.

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

CY2016 Proposed Rules for Radiation Oncology Released

The CY2016 Proposed 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 to be released in August. The Revenue Cycle Inc. team has thoroughly reviewed and condensed the proposed 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 Proposed Rule for Radiation Oncology – MPFS

CY2016 Proposed Rule for Radiation Oncology – HOPPS

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

CY2016 Proposed Rules for Medical Oncology Released

According to the recent release of the CY2016 Proposed 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 proposed changes for the medical oncology industry into two documents. To read the summaries, click on the links below to download a PDF.

CY2016 Proposed Rule for Medical Oncology – MPFS

CY2016 Proposed Rule for Medical Oncology – HOPPS

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

HCPCS Drug/Biological Code Changes for Biosimilars

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

Throughout the year, CMS releases quarterly code changes by way of the Medicare Learning Network®. Here’s a summary of how to submit the new code for the biosimilar drug Filgrastim (G-CSF).

MLN Matters® Number: MM9167 Related Change Request (CR) #: CR 9167 
Related CR Release Date: May 8, 2015; Effective Date: July 1, 2015 
Related CR Transmittal #: R3254CP; Implementation Date: July 6, 2015

Effective for Claims with Dates of Service On or After: HCPCS Code Long Description Short Description Type of Service (TOS)
March 6, 2015 Q5101 Injection, Filgrastim (G-CSF), Biosimilar, 1 microgram Inj filgrastim g-csf biosim 1, P

 

The drug Zarxio (filgrastim-sndz) is classified as a biosimilar. It is approved for all indications included in its reference product's (Neupogen®) label. Zarxio is a trademark of Novartis AG, is manufactured by Sandoz Inc. and is available in two prefilled sizes:

Injection: NDC 61314-304-01 300 mcg/0.5 mL in a single-use prefilled syringe 
Injection: NDC 61314-312-01 480 mcg/0.8 mL in a single-use prefilled syringe 

Changes in coding are constant and making sure that you apply specific payor guidelines is an important step in your documentation and billing compliance plan. The team at Revenue Cycle Inc. specializes in staying abreast of CMS news and more. We’ll make sure your staff is educated on the latest coding updates, trained to ensure proper documentation and implement effective checks and balances so that you can achieve your compliance goals. For more information regarding Revenue Cycle Inc.’s services, please contact our consulting team at 512-583-2000.